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f San Jtuin.CountyErvironmental Health iartment <br /> °A MASTER FILE RECORD 1N1=0RMATION.66 <br /> MFR" GREEN FORM <br /> SHADEDAgeAS FOR FHDusE ONS+.. SITE MITIGATION& LOP <br /> OwNERID# OASFZtxoa63�l UNIT !V <br />` OWNER FILEWOMPLETETHEFOLLOW/NG pROPERTYOWNER/NFORMArION. IF OWNER CurtrtF,v7xrov�7ee-wmr;EHD <br /> PROPEATYOwNeR NAME <br /> FirstM! <br /> Lost PHONENUMSen ' <br /> BUS[NIS NAatE y_ ..` <br /> E-MwlLAoDREss <br /> Owner Home Address f <br /> city <br /> STATE Z1P <br /> Owner Mailing Address <br /> Mailing Address CHy State Zip i <br /> '• �:•..:CORPORATt04�;"-''--�-.-.,.._��„--,INDNtaUAt: �..._.� <br /> "� �- ..�.. . ..p . n PART'NEit4NIP0. «-.��--...�,r--.••'*"fEOAGENCY _ OTHERCj- ,. <br /> $rrE MITiW1T10N_ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEMUP WATER QUALITY—HW PI>PRUNE INVEMrATION Lop <br /> FAcitmrlo# INV# ACCOUNTID PR RO# ASS[ NED EMPLOYEE. LEAD AaENcv:EHD <br /> � RWaCB—DT$G_EPA <br /> - L9Si� .5�'? <br /> FACILITYFILEE COMPLETE THEFOLLOW/NGBUSINESS IFACILITY/SITE/NFORMA770)w <br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTNIENTT YES © NO 5;� M <br /> Is this an ExianNo Business LOCATION but a NEW TYPE of regulated Business? YES © NO 1 <br /> BUSINESSIFACIDTYISITENAME A. / <br /> SITE ADDRESS Sut"#I BUSINESSPKONE <br /> ]WJ �a�,IJ,r r I7�3 1j16Pf c�q $J 3 <br /> C -^3� <br /> CITY C1/j_ <br /> 1 ate ZtP <br /> ` 5 3 /(o <br /> �r�v <br /> BOARD OF SUPERVISOR DISMCT LOOAVONCOOS KEY1KEY2 ' <br /> Mailing Address HOIfFERENrftmFacdftyAddhe= AtteniEan:orCare Of mptb_v <br /> Mailing Address City y STATE 210 <br /> SIC CoaE APN# CoIItMEttT 'E' "t <br /> THIRD PARTY BILLING INFO: Completetf RMUgg!'arty is different fromftoperty-Owner orFacility Operator identirredabove. <br /> 4,8usINEssNAaeE .:AtWrrition:orCare'Oi <br /> Halling Address04V K C ,t ' PHONE <br /> CRY _ STATE ``, /i _ LP 7 <br /> ,AGw&ATA,omni for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING F <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business;and I-acknowledge that all PEPhrIr eNES, <br /> PF.NALrtrs,F.,YroRCF.awrCHARCES and/or HouttLrCHARGES associated with this operation will be blued to at the address Identified above as the AccOuNTADDR2Ssfor this site.1 also certify that <br /> nil information provfded on this appikotion Is true and correct;and that all regulated activities will be performed In accordance with all applicable SAN.foApvlN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEuEKAL Laws and Regulations..As the undersigned owner,operator,or agent of the property located at the above facilitylsite address,I hereby authorize the release of <br /> any and all results and environmental assessment.information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon-as it is-available and at the same time it is <br /> provided to me or my representative. o <br /> APPLICANT NAME(PLEASE PR1NT) �jd � rim! SIGNATURE <br /> TITLE �1-�c o j TAX ID# g Q 0 2 7 7�S <br /> Approved By I Onto Aciooununy OHten Precon aln Com leted 8 Data <br /> SITE MMOATION ANDumT PAID ;;DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RecEFVEDBY WORtt PIAN PE <br /> I <br />