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• San JO*in County Environmental Health Department GATE / MASTER FILE RECORD INFORMATION"MFR" GREEN FORM LL-,,q SITE MITIGATION&LOP SHADED AMM FOR EHo USE CNIMMIDO t;,, UNIT IV OrMlII NLE.-COMALEW 7W FOLLOWYAfO PROPEM OMER/NFoam w.' Cnoe aver,owN.�ER Cim aEwnYomF wrm EHD PRDPEMOMONAE First MI Last PHONE Numm BU$**MNAME GMAtL ADDREes TILF� � Z�iW f.�.. L L�`/r ✓Z Ownw Home Addream d CWj STATE J Owner Mtriktp Address V S C Mzo 5�a CoRPORATtae❑ bomottAL❑ Pmmamr❑ Fm Aw cv❑ OTN SM MrF MTM_DIVIn W1 ff l ABMWMW K VOURrfARY CMWW_WATM QIIMM NW NNtJNE INVEI<TIRATION_LOP_ facrLmi0! It" AccouNT10 PRIVROO Ewn; Vw IEAu�oEnCriEHD __ RWQCB___DTBC�E#'A FACILITY FILE CommETBTHEFoLLOww BUSINESS I FACILITY/SITE 1AffVRA4T/aV-' to this a NEw BuWnen LOCATION not PreviW*reputated by the 9WIROMMMITAL HEALTH DEPARTMENT? YES ❑ iii Is this an El wow BIIakwas LOCATION but a NEW TYPE of regulated Business? YES ❑ NO BuetNEW FAca.rrrlBrm NAME f=© !t- < t CG L SrmAOams SUITE# stts amp"ONE I�-c-Ctit1 - Crrr -y._0 G l e--'- STATE Zm BOARD OFSUPERvtaORDt OWT tAOATMNCOOE I EL D l Msiirtp Addrew APGM995REN *vm FaaaWAahrw Athwdion:orCare Of(opdorsa1 MsWMAdd-Clty STATE LP WC COOS APN i COaaB1T 'Mum Parry 81LIJ11�INra Complete if Bitl' P is different from owner orF wed above. BUSIM eNAW Attwrtlom tarCare e O I c� MmOVAdd t©t !.J u t 8 5` O'7 4.t� `,m, c,2' T TE ZIP forfem and Ohw9w OWNER FACIUTY/BumEw THIRD PARTY BR.UNC BU.nvr A"['n&ITuANCE Acravow[a QMEKT: I,fhe ondersigned Applicant,cer"that I am dse Owner,Operator,or AatboKW AgeW of thb Imo,and I acknowledge Ihat all PFrum'F)s, PZ?VeL7rEs,ENFORCEMU rCkmIRGEs and/or HOUREYClumEs associated with this operation will be billed tome at the address identified above as the A DOWT tzpxFss for this site. I also certify that as information,provided on this application is true and correct;sad that all regulated activities will be performed in accordance wild all applicable SAN JOAgm COUNTY ththmoee Codes and/or Standards and STATE andlor FEDERAL Laws and Regulations.As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of any and all results and enviro msental assessment®formation to SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to the or my representative. J APPLICANT NAME(PLEASE PRINT) -3P id-.f4 —/ZZ-GC 5 L C "_ SAT TAIL ID 0 TITLE papa Accounts OIRce Date SITE MITIGATIONAMOUNT PAID DATE t)F PAYYBIT PAYME7fT TYPE RECEwT t CNEOK k REcewED By WORK PLAN PE FEE:;