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San Jc*in County Environmental Health cortment <br /> DATE �2�ZZ�� MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> SITE MITIGATION& LOP <br /> SHADED MEAS FOR END USE ONLY OWNER ID# cA9EM UNIT IV <br /> OWNER FILE:COMPLETETHEFOLLOW7NGPROPERTY OWN ER/NFORMA770N. ORtcrerOWNER 0vRRENlLroNezY wmEHDLI j <br /> PROPERTY OWNER NAME n / <br /> (�,be { ( ) <br /> First Ml Last PHONENUMDER <br /> BUSINESS NAME / j / EfAMLADORESS <br /> lit]C-C. ( (�`/� t C^ ZSR <br /> Owner Home Address <br /> � 1 0 <br /> city STATE LP <br /> Owner Mailing Address <br /> Mm#fIg Addre�cRy <br /> A ,U State ZIP <br /> CORPORATION d INOMDUAL❑ PMTNEnSHIP❑ Pin AGENCY❑ OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER OUALRT_HW PIPELINE INVESTIGATION_LOP_ <br /> ffff:�84A,00::j= AssIGNED ENPLOYEE LEAD AGENCY:EHD_RW41CB_DTSC_EPA_ <br /> FACILITYFILE COMPLETETHEFOLLOWING BUSINESS/FACILITY/SITE/NFORMA770AV <br /> Is this a NEW Business L.ocAnoN not previously regulated by the EWRONMENTAL HEALTH DEPARTMENT? Yes ❑ No <br /> Is this an ExIsnNG Business LOCATION hUta NEW TYPE of regulated Business? YES,0 No ❑ <br /> BUSINESS/FAcILrrWSc ENAssE be 4 <br /> I <br /> SITEADDRES9 <br /> � <br /> L r✓l "J{.Nt. �� �w � � SUITE# 81141NE93 PHONE <br /> CITY ( O / <br /> SPATE ZIP /r <br /> BOMDDF$UPERVI90q DISIRIGT LocABQNCooE XEYT RE'R <br /> Mailing Address NOIFFERENiefrom Fac#fyAddross Attention:orCare Of(opf/on;W) <br /> Malting Address Gty STATE LP <br /> SIC OWE � APN# COMAENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is ddferent from Property Owner or Facility Operator identltiedabove. <br /> BuslNEss NAME Atanti :aroare Of(olodonat) <br /> Mailing Add - PHONE <br /> CITY STATE ZIP <br /> Ac=uyrAaDpEw for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE.ACKNOWLEDGMENT: I.the undersigned Applimat,Certify that I am the Olvnv,OP,,AAoq or Amhwced AgeW of tbla 6asiaas,zod 1 aclmowledge that sll PFRVTT P$FT. <br /> PFNAY77F_g FNFOFCEnresir OWGU auditor ffGURLP OCIW,&Vasaoclated with this operation will be billed to.,at theeddras identified above as the 10cormmjrwsF for this site. 1alaocerfifvthin <br /> all informatlan provided on this application is true and mussed and that all regulated activities will be performed!in att,ordance with all applimble SM JOAQNN COU Ordinance Cotler and/or <br /> Shodardsand STATE and/or FWEEAL Taws and Regulations. As the undcrsigued owner,opeeatar,or agent oflhe properly/prated At the above facWtylsite address,l hereby authorize the release of <br /> say and ell results and environmental assessment hfdrmadan to SAN JOAQUI N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time it is <br /> Provided to me nr my repraenfative. <br /> APPLICANT NAME(PLEn EPRINT)W 1. Uti,I, �� f 1([y SIGNATURE tVL.�// <br /> l.�✓i-.rsr_� hh��W'W <br /> TITLE < _ r TAX ID#+' 1° <br /> Approved By Dab Aaourltirg Office Processing Completed By Date <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK RECEIVED BY WORK PLAN PE <br /> FEE: <br />