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San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> SITE MITIGATION&LOP <br /> 9HADE0-AREA13 FOR Edo USE ONIAL NientIO111 �33 G:, _FCASE it UNIT IV Ow <br /> OWNER FILE:Compl-F7'E THEFOLLOWING PROPERTY OWNER INFORMATION.' Cyromjr OWN F-A Ov YrxroseiltewirH E H 0 El <br /> PROPERTY OWNER NAme —'T;MI I <br /> —------------ <br /> First AV Last PHONE NUMBER <br /> BUSINESS NAME E-MAILADDnass <br /> C- <br /> Owner Home Addreau <br /> city STATE ZIP <br /> Owner Mailing Address qq5 ) I c10 <br /> MallingiAddresuCk It State CA Z43 4?5-2 <br /> CDRPORATIOtx INDIVIDUAL[] PARTNERSHIP 0 FEuAGENCYC OTHER El <br /> 3fT11I MITIGATION &MRONsliaNTAL AwitumeNT VOLUNTARY CLEANUP—WATIRR QUALITY HW PIPKILINIE INviltilTioATiON—LOP <br /> FAcILITY 10 0 INV# AccoUNTID ASSIGNEE)E EE o Aiss or.EHD RWQCB—DTSC—EPA— <br /> FACILITY FILE Compl-ETE rHEFoLLow1Na BUSINESS/FACILITY I SITE INFORMA TION.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Isthis an EXISTING Business LOCATION but a NEW TYPE of regulated Bustrieks? "s El No <br /> SUSINESSIFAClUTY/SiTs NAME <br /> f A Lo=A...oY.E�HD <br /> SITE AvoRess 'ii SUITE# BUINNESAPHOWN <br /> CITY C4,TE zip ca <br /> BoAnD or SUPERVISOR DSrrmcT LOCATION 00 Kffyl _._Kffy2 <br /> Mailing Address ifDIFFER&Tfrom Foallily Addriop Attention:or Care Of(optional) <br /> Mailing Addreas City TATE zip q <br /> SIC CODE APN N <br /> THIRD PARTY BILLING INFO: CotliplOte If Billing Party Is different from Property Owner or Facility Operator identifled above. <br /> 81.18fNeSSNAME '9 r�rs Attention:orCsra Of(optional) <br /> PHONE <br /> Mailing Address (9,;0 plevz'A T> S ie. .....Loo <br /> CITY ) STATE zip <br /> —"q � <br /> ' olels OR$1 CA ... (....... <br /> i -- <br /> 04caaLm4ilza for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND CONIPLIANC NIEN'r: 1,the undersigned Applitim�certify that I 3m the Owner,operator,or Authorized Aged of this Business,and I acknowledge that all PERmir F&,s, <br /> PEN,arrEs,Ereroaco*=A%�=Hoc'RLYCff,4FGk1S associated with this operation will be billed to me at the address identified above as thcjcc0[24aADp for this site. I also certify that <br /> all Information provided on this application Is true and correct;and that all regulated activities will be performed In accordance with all APPIIC91114!SAN JOAQUINCOUM Ordinance Codes and/or <br /> Shimiltirdiiand STATE and/or FEDERAL LAlws and RcgOadomi.A,1huride"l,"Idowrimr,operator,or agent anhe Property loomed at the above fadfitylill,address,I hereby authorize the ir,lerdc of <br /> any and all resaills and environmental nsitessment Information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE AICTMENT as uon <br /> as <br /> available and at the some time It Is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) TAX ID# <br /> TITLE f) <br /> 1 -4 <br /> By Data A....nVnq(lfflcia *.asisIngGornpleWDate <br /> bled a -y <br /> REcr-iveD By WORKPLANPE <br /> SITE MITIGATION AMOUNT PAID DATE!OF PAYMURT PAYMFNrTypr IPT 0 <br /> CHaoKill <br /> Far:I <br />