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• <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARTMENT <br /> DATE MASTER FILE RECORD INFORMATION"MFR" I <br /> GREEN FORM <br /> SITE MITIGATION&LOP <br /> lk'D AEASFOREHDNaEO1A_T OMERID110000/99oi FCAPEi UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNEW RESPONSIBLE PARTY INFORMATION: CAedrA�oNAALReT/a CMBMNTzroWNLe MRN FJID❑ <br /> PBwattOWNaI NAYS �; :� it <br /> Fmsr Mf LST4� PHONE NYt•al <br /> sua f NASE Ea1AN.AtnPer <br /> QMRIIHD Maws <br /> Gly BrATE Zr� <br /> OWNER Mmuw ADDRESS - <br /> MALLINO AOatESe CITY STATE ZIP <br /> ❑OORtgRATNRI ❑immmuAL ❑PARTIIEASHP ❑GOVEItHYENT AGeNDY 4RESPONSIBIE PARrY ❑OTIER <br /> SITE MITIGATION_ENVI RONMENTAL ASSESSMENTLU Y Lm P_WATER QUALITY_HW PIPELINE INVESTIGATION_LOPIF _ <br /> FAOILm IDI INVi AccaINTID PRif ROP A 0 E EMPLOYEE LEAD ADENcY:EHO_RWOCS�DTSC_EPA_ <br /> pOZ?J(6 Nlll Ro S9y J&(Ifvwj <br /> FACILITY FILE:COMPLETE BUSINESS 1 SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No in <br /> IS THIS AN EXISTING PROJECT LOCATION,SI A NEW SCOPE OF WORK? YES [8, No ❑ <br /> BUSINEsWAal.rfYfSDEfPRWECT NN! �_�,i k-« . - '!r• <br /> SfIEADOPESSf PROJEOT LGDATtaN xT - SISIEi BUGNEM PNCNE <br /> CT• STATE ZIA <br /> BOMO-S--OIBTRICT QI LOCATION CODE � ' KEYt KEY2 <br /> MMDMG ADDRESS,IF DSFEAENTfRDY FAraun Aoalesi ATrENimN:mOANE OF(aermWAL) <br /> MAILING ADOPESSCm STATE LP <br /> SIO coax APN0/ CtYwe+r <br /> 9- n <br /> Io <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ATiEKtADW ORCARE OF(OIAIIOANI) <br /> MMuNO ADDRESS PHONE <br /> Cm STATE DP <br /> ACCDurrrADDREsa TO SENO FEES AHO GIAl10Ee: OWNER FACILITY/BUSINESSO THIROPARTYBILUNG❑ <br /> JIMLING AND CA WNM 4 the undersigned Appltean4 AA rfy Wal 1 em the Ox er,Opuvror,Amhanu4AgrA4 w RMomaibla PAM and i actmoMMSe that AS PEXwFEFs, <br /> PEKfLtlF.f',F.NFO.KEAIENr CHA1N'ES aDd/or hfocwrCUACM vwcMM wkh thI project wW he NSM to meat ft Mdrm HemlfiDd above as We ACCWNFADDR for this dM.1 also certify that M <br /> Infmmadon praAlN on falls applkaban Is tree sad comct,and itat all regaiatcd xtividm Trig W performed b arearAace with e8 applicable Ss.Y JOAQUIN COUNTY ORDEI.WCE Cows mMlor <br /> STA\7)A AM STATE mWor FEDERAI.LANA AM RCGULATIONS.As 1M sasdenign &A ,OPW' ,AMiorfcrd AgaI ar RapaA WTO•for We project bested above n facNity/site address l <br /> ScrcM1y amhw'vs the rek.rr of eny vM all rmam,rtpnrts,Aed ether emironnlevbl avenmeR[Ivfornwbe M SAN JOAQuhv'c= nTRD'T RtAL l eP .GNT u sone m k I vveilable <br /> uM At IDA same dme It is provided to me or my sv Atadve. v <br /> APPLKYJTr NAYE(PLDABe PNRlTj ls:"r;•�; '- `''� t' f.`�' 1... S�� <br /> TITREy7c!'', — " F F- q. .—TAx10N C/� oO-6/53�6� <br /> APPAw®BY DATE ADDgWnda IXH�CEP"ROIYSBIIq GOMPtEfm Sf OATS <br /> SITEPMO DATE OF PAYYEM PAYYENTTPE P RECEVTP CNECKP RECENED By <br /> ylpnllPUN PE <br /> FSJ <br />