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San Join County Environmental Health Dertment SQ, <br /> b� � glC <br /> DATE f 2 I I 4 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION <br /> 1& LOP <br /> BHAOEp EA8 END USE ONLY OWNER IDB CASE# UNIT •V <br /> A <br /> OWNER FILE:COMPLETE THEFOLLOMNO PROPERTY OWNER INFORMATION.' CHECK IF OWNER CURREM YONnLEWnW EHD <br /> PROPERTY OWNER NAME YII�J <br /> First M/ last PRONENUMBER <br /> BU 11MNAMEa fnt E-NAILAOORESS <br /> rn�r- <br /> Owner Home Address , <br /> city STATE DP C?52 Ci <br /> �l o <br /> Owner Mailing Address t <br /> Mailing Address CRY <br /> OpgpORpTpN�(J INDMWAL❑ PARTNERSHIP❑ FED AGENCY El OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACWrY ID# INV# <br /> Accouw ID -ABNROlfA991GNED EMPLOYEE LEaOACEHcY:EHD_RWCfCB_DTSC_EPA_: <br /> flats <br /> FACILITY FILE COMPLETETHEFOLLOWNGBUSINESSIFACILITY/SITE INFORMA710N. <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YEs ❑ NO <br /> 01 <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? Yes 17f No ❑ <br /> BUSINESsIFAcKrY/SIrENAME [.) O d" <br /> Y" t <br /> ){yam l./ ,�.ri Q SURE# Busimeas PHONE <br /> SrTEADDREas r> >U�'l /t./c`I "Y 4l / lw (. `� <br /> CITY �/ ql{ / STATE LP <br /> mit- � e5 A �� z-a 0 <br /> 80ARG OF 5GPERYLsors Dlsrmcr LoonnoNCoDE ICEY'1 KEv2 <br /> Malting address YDIFFERFNr#oRrFeCAW Addi Attadbn:oroare Of(aPffoaW) <br /> Melling Addraee CRY. --1 STATE LP <br /> SIC CODE APN# I Comiewn <br /> 11 <br /> THIRD PARTY BILLING INFO: ComPiete if Billing Party is different from Property Owner orFaclllty Operator idendfied above. <br /> B1131NE33 NAME �yJ4L..� (( Attention:wCava Of AP&md) <br /> PHONE <br /> STATE <br /> CITY <br /> St c C �9`�2l-S <br /> AccOum'AnnRESR forteesandchaMes OWNER. FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING A"COMPLIANCE ACXNGwLEeoMENY: 1,the nddersigned Applicant,certify that I am the Owner,Operator,oc ANtharizedAgent of this Buenas,and 1 acknowledge that all PERSRFPFFT, <br /> PFNAMIF_%FN}Cp EMENTCRARGES and/or HOURLYCHAWKv associated with this operation will be billed W meat the adds,identified above as the AC oa ADDRESS for this site. I also certify that <br /> all Information provided.on this application is true and correct;and that sa regulated activities will be performed in accordance with all applicable SAN JoAQu1N COUNTY Ordinance Coda amt/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facUlty/sne add".I hereby authorize the release of <br /> say and ski..IN and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT As soon as it is available and at the same time it u <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEAsE PmNT) .�( � 4✓kt �.t71f�+" _ SIGNATURE W/!{y � { •, <br /> TAX ID#' 1 ^ <br /> TITLE L'. et' �i'p �llx <br /> Apprwad ay Dees- Auom,tine oMa.;11,11: 1!1!1119 Gmopleled By Y�f- Data <br /> SITEMITIGATION AMOUNT PAID DATEOFPAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORKPLAN PE <br /> FEE: <br />