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San Jo,- lin County Environmental Health Dr�rtment <br /> DATE MA ER FILE RECORD INFORMATION TTM11K j GREEN FORM <br /> SITE MITIGATION $ LOP <br /> SHADaO ARFwa FOR ENO udE ONLr OWNERIDMj �+ 4 ;C/ CAEEA ;2 a r r L:R. <br /> UNIT IV <br /> OWNER FILE:COMPLETETHEFOLLOW)NGPROPERTY OWNER WFORMAT70N: CHEcKIFOWNER CORRENMYONFILElstfrlEHDEl <br /> PROPERTY OWNER NMIE <br /> First M/ Last PHONE/NUMBER <br /> BUSINEss NAME E-411IAIL ADDRESS <br /> YUnd food <br /> Owner Home Address <br /> 971 �i a 8� <br /> CRySTATE ZIP <br /> oil CIA' l/' Zyo <br /> Owner Melling Address <br /> l iKL AS AIdt,L' <br /> Mailing Address City state Zip <br /> CORPOMTION❑ INDINOUAL PARTNERSHIP❑ FEDAGENLY❑ OTHER[I <br /> SITE MITIGATION_ENVIRONMENTAL ASBE53A ENT*/VOLUNTARY CLEANUP_WATER QUALITY_NW PIPELINE INyELTIGATION_LOP <br /> FACIL{{MIDR _ INvR11C000MID <br /> 3F t ,r N:,h ' . 1t ... u 1 0011411,110,11 - <br /> FACILITYFILE COMPLETE THEFOLLOW(NG BUSINESS/FACILITY I SITE INFORMA77om <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRoNMENrALHPUTH DEPARTMENT? YEs ❑ No ❑ <br /> Is this an EXISTING Business LOCATION but NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BuslNEss/FAclLmfsnENAME (�LLLrr/Z4.S ID c- At/..1( MAI12— . <br /> SREADDRESa 14 9.11 . \ ' I `Lf F- SURER BUSINEae PHONE <br /> Cm I`"�ID D I ,,-+ II,�1`� w o STA- LP <br /> BOARDOFSUKRvtsoRDmTRicr. LocAnoN CooE KEY1 K6fL <br /> Malting Address HD/FFERENrfiolmFaa1*Adtlreea Aeerdldre wCme Of(opCauf) <br /> Mulling Address City STATE Lp <br /> 81C CooE ApNN C-aA <br /> R : � E <br /> THIRD PARTY BILLING INFO: Complete i1f Billing Party is different from Property Owner OrFacllity Operator ldentifled above. <br /> SUSINESSNAME /J /1)A I 1 s/. R 1 1?d.11 Attention:o-Cere Of(olio leg l RryCN <br /> / 1Uf / � ✓lc-CI <br /> Melling Address PHONE <br /> y,7� as �f. 3i err l)aYk ter. � oo 14;,f- 2Sz-83�� <br /> CSTATE m <br /> YL7 e C vl'1 <br /> a ep Ln1 Z5-96 <br /> 9LYADd2AODBESs for fees and chargee OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERM "T ,, <br /> PFsucnFs,ENtroRCEarervrCNxwaand/or ROURLYCNA uassociated with this operation will be billed to me at the address idendfl d above as theAtt i%vrAnoREcs for thissite. I also certify that <br /> all information provided on this application is true and correct;and that an regulated activities will be performed in accordance with all applies ble SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,oragent of the property located at the above facility/site addre e,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM es soon as it Is ava0able and at the same time it is <br /> provided to me or my representative. h <br /> APPLICANT NAME(PLEASE PRIrn) )i oyyfh 1 /'ro WG✓ SIGNATURE <br /> TITLE / ,1 1 ,/s TAX ID# <br /> AW. By Dates Aaaourltlnp Omce P.Irt,Completes!By Data <br /> SITE MITIGATION AMOUNTPAID - DATEOFPAYIIENT. PAYM TYPE 'RECEIPTM CHI K REGENED <br /> FEE:III; <br /> � <br />