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San Joaquin County Environmental Health Department <br /> /I MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> DATE � ( ?j ! �3 SITE MITIGATION&LOP <br /> fRistill)AREAS'OR No Use ONLY OMNERIDS 610001213✓ Cases SQ00e690Z UNIT IV <br /> El <br /> OWNER PN l:CoMvc n eFo, Low�NG PROPERTY OWNER INFORM4770N: cNecgrF <br /> OWNER cungEvrzra f�xm EHD <br /> PAOPeRIyow NaN¢ ` <br /> Frst MI Lasl PHONENUM06r <br /> &YYLApamaus <br /> Buealse NaMe i� l� ' 11 nl � <br /> Owner Home Address WI's 1 <br /> STATE LP <br /> City <br /> Owner Melling Address qQq ZJ <br /> ^^ <br /> McII1nBAddress City S5vo�. S n p <br /> 0n Ab f� <br /> L)2--7- <br /> CGxPa+ATrox <br /> IHGMOQM1L❑ PMrNFA4mP❑ FWAG 11 orNME] <br /> 317E MMgATIoH_BNNEOMMENTALAUMMENT_VOLUNTARY MMMUP_WATMt QUAUW_IIW PIPIIUNE INvwnGATION_LOP <br /> FACIUIY IDtl INvll AccotiNT ID PRXROs AnIGNMEMPLOYEE LPAo AGExCY:EHD-Y--RWQCB_OTBC_EPA_ <br /> �YDO I7 D3�1 �-053�D �foNNNy <br /> FACILffYFILE CouvcETHrNEFO(.LOWNGBUSINESS IFACILITY ISITE INFORAIAnoN• <br /> Is this a NEW Buslntu:a LocAnON not previously regulated by the ENNRONMEKTAL HEALTH DEPARTMENT? Yes ❑ No L9� <br /> Is this an E%ISTINO Business LOCATION but a NEW TYPE of regulated Buslnesa? YEs ❑ No 63 <br /> BUKxmalFaclfmlBtsENarM !v�/ _C� <br /> 9rrEAaoRma l• Burk 9UEMEea PHONE <br /> C" STATE �g53ot <br /> BGumaFBUPEiMeatDIETxCT LGGl10N Cone 03 Ke't KET2 <br /> Malang Address ffDIFFERENTIran,FacWAddress Allen ion:oroere of(ophOnsf/ <br /> STATE LP <br /> Melling Address City <br /> I aa <br /> Btc cope C0"p1A"' <br /> aaNs z� QUO"�(o <br /> THIRD PARTY SILLINO INFO: Complete if Billing Party la tiftfaildffamProperly Owner or Facility Operator ldenHHedebOve. <br /> BuaxPas NAaM t/1 n 'n kv.1 n Attention:wCare Of(0011ROU -7 (/ <br /> M.ning Address h [/ (1, S STATE 9 tl r'I I Z 7"- <br /> � rid-r>` Sv�-�c ZSo _/ <br /> Cm ATE q2 (,I g <br /> Apggk%D4Qpffiff forfeesendcharges OWNER FACluTYfBUSINESS THIRD PARTY BILLING <br /> @ C f IA tE ACK O E GMrNf: I,the wd,r i,ad Appanpt,certify that I am the Owner,Operator,or Authorized Agmt of this aminal,end I acimowledee fhaf as PERMIT F q <br /> PENALTIES,ENEORCEMFxTCxAEOFS evdlor ROURLr C/URGES usocleled wild this operation will be biked m me at We address identified above as the AttDVWADDE for Nis site Ialso certify Mut <br /> ea",=$fion provided on Muse anration u true end sort am gad Mvf W regulated vd,,,bE wal be performed m vmordanm with as appM.bIE SAN JOAQNN COIafY Ordiname Cada avdlor <br /> Standards and STATE and/or b [)E Laws End Regulatinoa.As the undersigned owner,oiler EN or agent of She properly lH DE atlbe above as son..address,I b la En authorize are rimae of <br /> any end au malts and as Uoamenbt aammmt Information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT u soon u it u avaiNble avd of We arae Iume it u <br /> provided to me or my repmamatire <br /> APPLICANT NAME(PLFABE PRINT) �arer " �, aioNATu E <br /> TAX 10 9 <br /> TITLEflun <br /> raved i>a1e Asxountl Gt110e Pracaul C it Wb <br /> Sita Mams"'.N Araoulrt PNO OATEOT PAYYENr PAyraENfTYP! RECEIPTP CHICK ReoDvm BY Wo9l OPE <br /> Fu:A 375 3�5 3 91! <br />