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R � 1 <br /> f <br /> San Juin County Environmental Health Dertment <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> D Z� SITE MITIGATION&LOP <br /> BHaDEe aRFAa roa£NDl/iE DrRY _ ow><,�to# cASE# UNIT IV <br /> OwNM RLE aCoMALmnHEFoLcowrNoPROPERTY OWN <br /> {ERhwoRiwano►v: qNECrrFOWN ERCuRRkwnyONr-xEwnHEMD� <br /> PROPEMYOWNERNAME <br /> Fist Mt Lest PRONE Nulla m <br /> StMINEEs NAME E-YAILADt7RE86 <br /> Owner Home Address �� ��..�e�.>•.� E-t-c fZ.�-�► V <br /> city STATE ZJ <br /> A <br /> Owner Melling Address L2 <br /> Melling Address City <br /> CORPORATION❑ IYIDUAL PAWM RSNIP© FED ANNOY❑ OTHER❑ <br /> $ITR UnIGATIDN_EKWM)MKMTAL AJIStBtUMT VOLUNTARY CLEANUP_WATBR QUALITY HW PIFW WL!INVEWnGATION LOP <br /> d,. z <br /> FAdem ID# IrIVA AexouttT IQ PR#I ROtt , <br /> FACIUWRM CorwALrWrHEFOUOMNG BUSINESS FACILITY1SITE INFORAW70N. <br /> Is this a New Business LOCATION not previously regulated by the ENvIRONMENTAL HEALTH DEPARTMENT? YEs ❑ No P <br /> Is"an Extimma Business LOCA-noN but a NEwTYPEof regulated Business?. YES .❑ No <br /> BuelNEe fFAcILffW&M NAME y ej . <br /> �t' B P� BUti1NE) ," <br /> SFre AooRr:ea ..•l � � � • (1�uric � <br /> CITY STATE ZJP <br /> BOAM OF SII W.W111M DteI MI LOCAT1w1 CODE ', KEW KEIrt <br /> Halling Address IfOIFFEREWr1ram F Addrtea Attention:arCare Of(opthrra) <br /> Melling Address City STATE ZIP <br /> 81C oDDE � APN ��� I �� w►c�. 1-� .!'� � �G� < <br /> TNNm FART1f WLLIN4 INFOI Comlets K Billing P Is dHferent from Property Owner or Facility Operator ldentflled above. <br /> Busimm NAmEAttention:arCars Of.(apt/ons1J <br /> e�(�t�t a a C Z i ra.J I -, <br /> PHON Mailing Adele sw 2 �wS-( E 2v- D 7 <br /> Cm STATE ?SP <br /> G <br /> tvrtees 14dehary11 OWNER Fac uTyl usmw IRQ PAR c <br /> 1,the cm8er tMd Applicant,certify,that 1 ate She owner,operow,or Awbvrhsd Alcof of this Bwlnen,and I adcac iedge that all PERA 1'esa, <br /> Prs•ALMS,E vmaC ONrCHARMs aadtorRODRLrOfAlr=asodated with this operation wRl be billed tame at the address Idendlled above as the for this site. i aha cerdry that all <br /> information provided an this application is true and correct;and that aY regulated activities wig be perfarmed In accordance with all appllcsbk SAN JOAQwH Cmm'Y Ordlaaaee Codes andlor <br /> Standards sed SYATs nodlor FXOreAL Laws sad Papdatlolrs. As the u denlgeed owner,operator,or agent of the property located at the above fadlitylsite address.I hereby outlwrta the release Of <br /> any and an resells sod envlranmental assessment Idarmatton to SAN JOAQUIN COUITTV ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same dim It Is <br /> provided to not or my representstlwe. <br /> APPLICANT HAME(PLEASE PAWT) SIGNATURE <br /> TITLEt 1 t�A TAx I D# r cm <br /> Date Aooaedlnp ORiaa PTCCpaIn9 Camp!etM BY Date q!�. <br /> SITE MmGA AwwwrPAID DATE OF PAYMENT PAYMEHTTYPE RECEIPT/ CHECK# RECEIVED BY :R P� <br /> ! yrr;r <br /> FEE:; <br />