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0 0 <br /> San Joaquin County Environmental Health Department <br /> N 41 MFR GREEN FORM <br /> DATE L� J `i 3 SITE MITIGATION&LOP <br /> g NO Ot777;7(--6 <br /> Sb2 UNIT IV <br /> OWNER FILE:COMPLETEnfEFOLLOW/NG PROPERTY OWNERINFORMAnoN: CH�KIFOWNER CuRRENrtroNFnEw EHD� <br /> PRaPExry OwttFR Nate <br /> Firsf MI Last PNONE NQataEA <br /> ( e fANJLAOMEss <br /> BuslNEse NAME <br /> Owner dome Addreas <br /> STATE LP <br /> City <br /> Owner Mailing Addreee _!99 Lace �r\� state <br /> /� r� <br /> Meiling Address CRY �_!C IS _ LP <br /> ..j A CI d u <br /> CaePOPATNIN L`f <br /> INONKMAL❑ PARMw <br /> ERss ❑ FWAGENCYD OTNFPD <br /> SITE MmOAT1ON_ENVIRONMENTAL ASOBSEMEITT—VOLUNTARY CLEANUP—WATER QUALITY_NW PIPELINE INVESTIGATION_LOP <br /> FAORm IOe INvE Accouar lD PRNROS AGNEo EMPLOYEE LEAS AoeNcy:EHD_�/ RWQCB_DTSC_EPA_ <br /> �ouuivy <br /> FACILITYPILE COMFLETETHEFOLLOWNG BUSINESS/FACILITY/SITE INFoRmAnON., <br /> Is this a NEW Business LOCATION not previously regulated by the EiMptoNMEWAL HEALTFI DEPARTMENT? YES El No CV <br /> Isthisan EXISTING Business LocATIONbutaNEWTYPEoffegulOod Business? YES No <br /> Bu&NEes/FACRmISrtENaa <br /> C/vim <br /> Surma BuslN PNONE <br /> STAM <br /> 9nEAmREas fl�ro W. (-ICU`/\k��� � <br /> cm 7 7 LP953C)Z <br /> Kt-Aw <br /> Bo MSUPER•nsSe DMmcr LfX:AI%M1 Coo! j KEYt ReYL <br /> Malling Address NDFFEREVTswrt FacWAaWnsm, Ado dlon:SrCare Of NPUb-01) <br /> STATE LP <br /> Mailing Addrnea City <br /> BID cone C� <br /> APNS 23�L00�OL.O <br /> THIRD PARTY BILLING INFO. Comp/idE 1/Billing Party is different homProperty Owner or Facility Operator/dentlNedebove. <br /> Adamson:arGare Ot(opWrwO <br /> PHONMailing Addrem F` 7,5c> b <br /> STATE � G, C7 -�Z-"_ L� 11 /6 <br /> AqgqyffAgWW <br /> Dm - �"'� <br /> for fees and charges OWNER FACIUTYBUSINESS THIRD PARTY BILLING <br /> glil,iNGANyCowLIANF,LACR 0 E G EM: 1,Me undersigned AppNcm4 certify Met 1 am the Dever,DpeTmor,m Aodrorired Agent of Mu Bottom,2041 aclamPledge that RH PERMIT Fres, <br /> pFNALnES,ENFORCE.AIDln'CRARGu andtor RoollyCtG tSEs associated with this operation wet be billed tome at Me addreu identified ebwe as the ACCDONTADDRFSS for flus rife. 1 oho certify that <br /> as information provided on this application u true and core"(;and that W ragrdated activities Wal be performed is accordance with all applicable SM JOAQNN C'UIY Ordioanc eCthoedes'. <br /> or <br /> S"dardc and STATE mdtor FinE Laws and Regul &m.As Me undersigned owner opermor,or agent of the property located at the abovesmililyhar <br /> ih addr , by <br /> any and all ra.If and envdronmenml axurmrnt information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT w two a it N available and at Me came time it IS <br /> provided to me or my reps aotative (`-�`- <br /> APPLICANTNAME(REAeEPRIW) KQ�er �T�f� SIGNATINE )klx- <br /> /' 1. TAX ID A <br /> TITLE <br /> roved <br /> O� AccourN Ounce Pennant C Dea <br /> Bm MfrlaatioN I AMOQNr PAID DATE OF PAYMENT PAYMENTTYPE RECOPTO CNlORP ReeErvEn By Wo,NPLMPEj <br />