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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE i Tyr MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADEVAREAMFOREHOUSZORL.V CASE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTYOWNERI RESPONSIBLE PARTY INFORMATION: CxeclllPOWN MCVRREATLY0JFR wirN EHD� <br /> PROPFRIYOKIIER NAME M&r K b,;') d l <br /> FAST MI LAST PHOMENUMBER <br /> Busewm NAME & ILADunsws <br /> OMNERHDLE ADDRESS -`)'S2 S (AJ . S en' a 1 'Y) l-�-v 1 i- J r i g L A <br /> CITY s'Coc Oz 1 , STATE 2) 1 <br /> OMNER MAAWDAmMME <br /> MAILING ADDRESS Cm STATE 7- <br /> Ll CcImpowtamoii <br /> P❑COIROIIATKNN P(I.mv.DUAL El PARTNERSHIP ❑ODVERNMENr AGENCY ❑RFRON/BIE PARTY ❑ONRN <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_RW PIPELINE IN4F.9TIGATTON_LOP_ <br /> FACILm ID# INv# ACCOUM ID PRWRO# A#elall2 EMPLOrE£ gL�wOAgENDY•EI < :I�IWQCB. OTBC_EVA"'' ':. <br /> r <br /> f <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: �/ <br /> IS THIS A NEW PROJECT LOCATION NOTPREVIOUSLY REGULATED m THE ENVIRONMENTAL HEALTH DEPARTMENT? 'r <br /> amf ND <br /> IS THIS AN FOfISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES pp No ❑ <br /> BUSMESWACILmISITEIPROJECT NAME 'FbYM Gc <br /> SREADDEESS/PRONEOr LOCATION 1/J r�Q•(o 'V `C �T \ UDEs BUSINESS PHONE <br /> 1 <br /> Iva N :2 o a <br /> Cm 1\ n / •STATE •LP <br /> C,-' �I 3 O <br /> a— DFSUPERVISOR DISRe1Cr Loc.—CODE !, K-1KEY2 <br /> MAumG ADDRESS,IF DIFFERtM FROM FACILm ADDRESS V ATTENTOm:MCARE OF(OPTIONAL) <br /> "50 1'2 L-LAeeGtveh w o <br /> MAADGADDREMICm ^ C-0<11 N^n C� w STATE ZIP <br /> SICCODE 1 APN# ,1 COMMENT: <br /> TNIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSONEsS NAME 1 _a rATTERtow ORCARE OF(D'GrIOAML) <br /> IAAILMDADDREEE /o��(�12 `�Lu Le— (\v,.VA Lke --u k-5I1 O 3 PHONE 41921P <br /> STATE <br /> Cm G G,C k`A'1/t <br /> T/I <br /> AOCOUNr ADDREses To SEND FEES AND CHARGES: OWNERS FACILITY/BUSINESSO THIRD PARTY BILLIN <br /> BnLINGANDCOMPLTAN[EACHNOWLEDGMERT 1,the undersigned Applimo,crrtify NutI am the Owno,Operalor,Au✓Ioriud Agent,or Rapwible Parry SDd7 ulmavl<dgc HutaU PFJLWTFEFS, <br /> P£A'ALTTFS,ENFORLTATENTCMITUES and/or NOURLYCWARGA'a avbaed with this pmject Will be billed tome at the address identified above as lheA¢ouvrAmRFss for thu sim IalsocerrifythataD <br /> irdorrnatim provided on Hut appGeatiaO is tree Sold coreecr,and that all reQUlmed activities wdI be performed in accordance with all aPIU.ble SAN JOAQITOT COUNTY ORDINANLT CODES.&or <br /> STANDARDS and STATE=titer FEDERAL Laws and REGULATIONS.M the undersigned Owns,Q rralor,AUffiamedAgent,or RaponsWeParty for the projectlocated above under facility/site address,I <br /> hereby autharbe,the releme orany and SII retulU,mporh,and other environmental assmatrut fOTormaoon to SAN JOAQUD 4:0"11 R() vrAL HEALTH D Xr*,\ti\XT soon as it h evailabl. <br /> and atthe same tME(Pc it tp4SE PRI tomeor my mprrscntafivc. <br /> APPLIDAM NAME(PLEASE PRINT vA`-Cr� �a1�� SIGNATURE <br /> nS� <br /> TITLE -prd Ifl >�tihrti r TaxtD# q'5_ ///z1 <br /> APPRWED RY DATE ACWIRlDN6 DRICE PAOCES91NO C01lLL'!t➢MY DATE <br /> SM MmMTt.N AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# - RECEN <br /> FEE: ED BY 'rkYYDRR yEt_ <br /> s X75 3 7� X1.23 -ILI GII I/5( I Llo)23 IZZI- ' � ` <br />