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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE �J, I,z1 I MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> 1` //�� SITE MITIGATION&LOP <br /> BNAom aRE emaEN➢uW pNty OWNER IDS 01000 'S5g / CASE% C'LI.�w/ pI(-(p UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY/ INFORMATION: Y J CCN]ECKXOHWe ASCuaRe;Ynroms IOTH END <br /> PRgpERh'OMNER NAME (fir K v/`A,C 1 b A, All <br /> \ <br /> FlRST MI wr PHONE/HUMBER <br /> BWHESS NAME rr ,, TJ , E-MAILADDREB9 <br /> 0owESH➢MEADDRESS 3525 W fJ enM1 c.rvl+� 1-�-01� Jri.r� <br /> CRY \o` �iz Y, STATE 7- 0\5 219 <br /> WN <br /> OER MA4.101GAJDDDRRESS <br /> MAawG ADDRESS CRY YATE ZP <br /> ❑CORPOPATION dMDMUUAL ❑PARMERMIP '9IS EPARTY ❑DRIER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTAR\ /^` �r/ PELINE INVESTIGATION LOP— <br /> FAOILITYID% INV% AwouutiD PR d'JRO% ` \ 9 RWOCB• DTBC:. sEPA -,, <br /> Ffrpo22� ARoo`b17}fi PRo5�4f�3y ���ddd"' s �s. <br /> FACILITY FILE:COMPLETE BUSINESS/STTEI PROJECT INFORI �-/ <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRI _._, IMENT? 00 NO 1w <br /> ISTHISANEXISTING PROJECTLOCATION,BUTA NEW SCOPEOF WORK? YEs 5' No ❑ <br /> BUSHESSIFAMLRYISIIEIPROJELT NAME 7 ,(M ec <br /> Srrr ADDEESSIPRQIECTLOCATjoH 13$$ I'y1 URE% BUSINESS PHONE <br /> ca &3 0 <br /> BoARooFSuPD 11013IRw LODATOHCoce !' KerT KET2 <br /> MACINGADwIE .FoNFEREMFROMFACILRYAomt V ATTENfMN1:MCA11EOF(OP➢ONAL) <br /> '5012 LLA4,f_ Gtve�t ut o <br /> MAawO boRFssCm STATE LP <br /> SICCODE APN% COMMEHr: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSwEss NAME —TtA _a — �ce— > /-� ATSENDON:ORCARE OF(OPTA' j �T <br /> MAILWObwtEss �O 1Z— ` ` r--fL /JA "'(.��1 ��+� 1' �V 3 PHONE ,r I I 113' 2 � <br /> Cm M G G1 C l LI Yl ff V .F�- STATE ... (�L{5 (o <br /> ACCOUNT ADDRESS TO SEND FEES AND CHMOES: OWNERO FAcury/BUSINESS THIRD PARTY BILLIN <br /> RILLINOANDCOMPLIANCEACRNOWLEDCMRHT: 1,If.mxJ ipoed Appli.4 certify that Iaw the Own,,OpemloAAmhor4ofAgeol,w Rapomlbie Party and I ec;emrledge that A FP I,FkEiS <br /> Prx Lp IENFORmNRNrCA RCFBanaorHOMY4�VAR=Mmo led with thin projectwa be billcd tome at the addressidmdfiedabove as the ACCODATADDRFSSfor thisalk.Iabo eerEy tlNt NJ <br /> information provided on MD appGrstion u true and comet;and that all reDuh,hd acdvitlrs will be performed in accordance with all apptiuble SAN JOAQUM COUNTY OMINMM CODES and/or <br /> STANDARDS Sod STATE amitor FEDERAL Lawa and RECDLATIONS.Aa Ow umimipped Ol er,Op,mary AwhoriredAgeat,Or Rffp&LWe FSITY for the projeetleeated above under fauLylsile address,) <br /> hereby autlarire the release ofaoy and all rmulta,reperm,and other envirommmal aeorament w rmatioa to SM JoAQUM COUNTMRO AL HEALER D ANrsa soon As it if available <br /> the same <br /> andatcAwNtim(PLEAsvidcd tomoolr my rcpraenmtivel lefi ��+APPtJCAMiNAME(PLFASEPRINT) yAt"Cri $g <br /> TRLE fro TAKID% z'5- /z1 85/L/ <br /> APPR w DATE ACCWNiWO DPRCE PADCEaalNp poMPLeTm EY pare <br /> SITE Mm"TNw AMOUNT PAID DATE OF PAYMENT PAYMENTTpE REOEIPf% CHECKS RECENEp BY WORNP PEv <br /> FEEL4 3;74 3 �s �i,23 •III e,��Q� i Llo jz 3 �— .' � " Q <br />