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i® San Joaquin County Environmental Health Department <br /> I DATE \ � MASTER FILE RECORD INFORMATION"MF'R$' GREENFORM <br /> ., SITE MITIGATION& LOP <br /> SHADEDARFASFOR EHOUSEONLY OWNER IDN CASE# UNIT IV <br /> OWNER PILE:CCMPLETETHEFOLLOW/NG PROPERTY OWNER INFORMATION. CNecxrF OWNER CairrrEArrero,YrlceWIWEHD n <br /> PROPERTY OWNER NAME --a—; , ,r (grit) 799-- 1S <br /> First Mf Lost PHONE NUmaeR <br /> BUSINEss NAME EMAIL ADDRESS <br /> S Owner Homo Add rase <br /> s <br /> City _ STATE ZIP <br /> Owner Mailing Address <br /> 5+ S+, :Ie 100 <br /> Mailing Address City t Stato � Zip 9 5"2 q <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OrttER❑ <br /> SITE MITIGATION_ENVIRONMENTALA6sels>smaNTVOLUNTARY CLEANUP_WATER QUALITY HW PIFELINE INVMIGATiON_LOP_ <br /> 3 FACILRYIDII INvN ACCOUNTID PRNIRI AtLetaNaDEMPLOYt LsADAm=EHD_RWQCB_DT60�EPA <br /> _ <br /> j FACILITY PILE COMPLETETHEFOLLOWI o BUSINESS/FACILITY I SITE INFORMATION.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YE s ❑ No <br /> Is this an ExisTING Business LOCATION but a NEW Type of regulated Busine s? YEs ❑ No <br /> BUsiNEaWFACWTYISITs NAME / <br /> E ^ <br /> StTEADDRess ` ( ' 't ' { SUITEN BUSINESBPHONE <br /> CIN1 C4TATE ZIP L!^ ca <br /> C4" <br /> BOARD OF SUPERVISOR DISTRICT <br /> LOOATION GOD[ KsY1 KsY2 <br /> c <br /> Malting Address NDJFFERFI�Tftmm�NRyAdd�V� � AttenUon:orCere Of(opVonal) <br /> lA"51l 14r. L t, <br /> MallingAddrees0ltyRc)"D e v .— <br /> C !STATE ZIP (; q <br /> SIC CODE APN N CostMarr: <br /> 1 THIRD PARTY BILLING INFO: Complete If Billing Party is different from Property Owner orFacility Operator identified above, <br /> % BuslNessNAMe /� �j <br /> CR �'=s U";" Attention:arCare Of(opf mlJ <br /> (2 �I1G+ t4CtGkdt✓ttj <br /> Mailing Addressn PHONE <br /> I"(Q2d pr SH.ie- Loo <br /> CITY STATE Zip <br /> EBccoDVTADnxess for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> BILLING,LNDCodtrLiANCE ACKNowLEUGMENT: [.the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Rosiness,and I acknowledge that all Ammar FSES, <br /> PENALTIES,ENYoRcrne rCHARGES and/or XOVRLT CH,4NcFa assoclated srlfll this operation{VIII be billed to me of the address Identified above as the ACCothyTAAAR@SS for this Silt, 1 also certify that <br /> all information provided an this application is true and correct;and that all regulated activities wvAl be performed In accordance with all applicable SAN JOAQUIN COurrryOrdinance Codes and/or <br /> Standards And STATE and/or FEDERAL Lars and Regulations.As the undersigned mvner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment Information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH A8 ARrStEN'r Rsoon as it is Available and at the some time It Is <br /> provided to me or my representative. _ <br /> APPLICANT NAME(PLEABEPRINr) C GtGfLtrftrf� 61t+NA " <br /> TITLE ProC'C's TAX ID* ca,� <br /> � J <br /> Approved By. _.. Oafa A000unbng Office Prooeeeing completed RyDate <br /> SITEMITIQATION AMOUNT PAID DATE or PAYMENT PAYMENTTYPE REOEIPT0 CHEOK0 RecavED BY WORKPLANPE <br /> Fcc:i <br /> I <br />