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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE 5.1 H_13 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> _ m SITE MITIGATION&LOP <br /> UNIT IV <br /> SHADED AREAE FOR EMD UEE ONLY OWNER ID# O A)'t1D I? 2, CASES / 7 / <br /> (/i I/ / i-:J L/ I e--CJ <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHOcKIFOWNRRFscuRRENrerONFReWITH EH <br /> PROPERTYOWNERNAME ER1 c,- SL v CKIS <br /> FIRST 41 L.esr PHONE NUMBER <br /> BUSINESS NAME VAC`r n 1-&r�� E-MAILADDREBB <br /> OWNER HOME ADDRE88 C1 G ri'V ��l <br /> CRY STATE ZIP <br /> OWNER MAILING ADDRESS NE �I W l O (� Tr'- „11, <br /> MAILINOADDRESS CIN ` �C S0 I\1 v `k LLe� I yI 1 J t G STATEr L- LP , 2-2 O7- <br /> CORPORATION ❑INIMVS:UAL ❑PARTNERSHIP ❑GOVERNMENTAGENCY ❑RESPONSIBLEPARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_H W PIPELINE INVESTIGATION_LOP <br /> FAGILITYID# INV# AO/OIIMT ID - PR#/RO# ABBtaNED EMPLOYEE LEAD AGENCY:EHD ,_RWOCB_DTBO_EPX <br /> 1�21�83 4�3�8 oo3�ibl � R�531 joOVA/ <br /> FACILITY FILE:COMPLETE BWWWW I SITE/PROJECT INFORMATION: <br /> IS THIS ANEW PROJECT LOCATION NO PR WD&WILY REGULATED BYTHE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No <br /> SUSINESSIFACILITYISITEIPROJEOTNAIIS I?J^ ` ©1 ' D\ . I <br /> OrTEADDNESSIPROJEOTLOOABON 1/►� W . 1 I "lS-re SURE# BUSINESS PHONE <br /> CITY r['�/) �C/[U�ll ,/J.-��'/� CA STATE ZIP <br /> SOARDOFSUPERVISOR DISTRIM S USE( MN CODE 3` KEY1 KW <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADOS[88 ATTENTION:ORCARE OF(OPRONAL) <br /> MAILINGADOBESSCIN STATE ZIP <br /> 810 CODE APN/ COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME I/J 1\ (LC 1� .�/ AI/' 'A1 T. 1n1� TP' TION:OR CARE 0! <br /> OPT1z, <br /> 1 40� r A WCL(I V I V IJST <br /> I�1 X1(6 PHONE S-I D <br /> MAILING ADDflEBB Ll <br /> 65+F- <br /> CITY O A`/ 1 AIN C srATe IP <br /> ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNER[:] FACILITY/BUSINESS❑ THIRD PARTY BILLIN <br /> BILLING AND COrIPLIANCE ACKND\VI.F.OGAIENr: 1,the undersigned Applicant,Cerliry that]nal IIIc OmneA Operator,Aalhorized Agent,or Raipousible PRrp,and I achnow edgc that all PcruurtE&S, <br /> P6 IZNFV,CNYORCE ATCHARGa nfid10l'110UR6)'C/GRGe:SnssDcintcdwith thisprojectisill be billed to alentthe RIldress NIenNBed above as III/ILYY)UMYN1Oum far this Site. I also certify(hat nil <br /> Infonnnfloo provided on flit,application is true and correct•,end that nil regitnted nrtiviflm will be performed in accordance Wilb a0 applicable SAN JOAQUN COUNTY ORDINANCE CODES Andfor <br /> STANDAIUIS and STATE nulllor I'):nF.RAI.Lnvvs and REGUTATIONS. As the undersigned OwNer,Operator,AullwkedAgent,or Reirol We fnl'IIICprojf located nbmrunderfnciliryhilanddlress,I <br /> hereby authorize the release of nay end all h,s,d H,reports,and o her enviramnenlnl ossmanent information ID SAN.ioAQOIN COUNTY E' NNA AL P TII DEISNTAIP.NT os Snalh ns Its OYAR:IIIID <br /> and at(hesnme tmeil is prmdded to meat yrep,owntve. <br /> APPLICANT NAM (PLEASE PRI HT) <br /> —TITLE TAXIDM <br /> APPROVED BY OATS ACCUURTINOOBYCEPROCEESINOCOMPL OBY OA1H <br /> BITE MI7z��DfATION' AM'OJUNT P/AID DATE OF PAYMENr�T PAYMENT TrPE REDEIPT# CH/E/ON#/ RECEIVED BY WONON(PLANPE <br /> FEE:$.//� :-J �'ZI_I ) ill[-A1 '1�T0 I? r te <br />