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i <br /> San quin County Environmental Health t4artment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" ILLGREIEN FORM '}ti <br /> 0 <br /> SITE MITIGATION &LOP <br /> X—, <br /> -SHADED AREAS FOR HDU ONLY <br /> OWNER-ID#-- - --" <br /> UNIT !V <br /> n y - <br /> ASE f1-c y <br /> OYIfNERFILE:COMPLETETHEFOLLOW/NGPROPERTY OWNER I/NFOR_AIAT/Om CNECXIFOWNER CURRENtLYOHFILEWITHEHO� <br /> PROPERTY OWNER NAME <br /> 001 210 •ct d <br /> First M/ Last - PHONE NUMB <br /> BUSINESS NAME - - E-MAILADDRE - <br /> Owner Home Address `J <br /> NOV.10 2w <br /> city <br /> STATE ENIRONMEN TAL HEALTH <br /> Owner Mailing Address <br /> [t�unjjAddress City I <br /> st R 9 U$i D <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> $LTE MmeATION ENVIMMMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIUA-nON_L,OP <br /> FACILITY IDN iNv# ACCOUNT ID '-RBakhRO# t ASSIGNED EMPLOYEE -- LEAD AGENCY EHD RWQCB OTSC EPA - <br /> FACILITY FILE COMPLETE THEFOccoW/NG BUSINESS 1 FACILITY I SITE INFORMATION.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No Ij <br /> Is this an ExST1NG Business LoeAmN but a NEW TYPE Of regulated Business? YES ❑ No <br /> BUsINESSIFALILITY1SrrE NAME <br /> Sh-k\ <br /> +ce <br /> SITE ADDRESS ^ -115 .� SUITE R BUSINESS PHONE <br /> CITY ThA /r 1{J\ <br /> SPATE ZIP <br /> g5S-1 1 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 -'k <br /> KEl2 <br /> i- <br /> Mailing Address IfD1FFEREAfrfh m Fm9liyAddrl7ss AtteWon:orCare Of(apVanW) <br /> t W We Dr. S 230 Joe Nem <br /> Mailing Address City STA <br /> P�On DM CA <br /> GS <br /> SIC CODE APN# ENT <br /> �_ r, <br /> C M f rd r r .wr <br /> oM m <br /> „ T r <br /> f <br /> fi ' � <br /> THIRD PARTY BiLuNe INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME - <br /> �5 � Attention:arcate Of(optional) <br /> oe <br /> Mailing address <br /> ode fir. Sup�R 23o PHGO •9133 - 231e <br /> CITY STATE YIP <br /> V ' -jW/ 14 <br /> A f Qlld rAmmms for fees and charges OWNER FACILITYJBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PEkhflm +$ <br /> PENAL77Es ENFORcEmEw CHARGES and/or HouRLY CHARGES associated with this operation will be billed tome at the address identified above as the Accoui rADDREss for this site. I also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQWN COCNTY Ordinance Codes and/or `( <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of 6 <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP MENT as soon as it Is available and at the same time it is If <br /> provided to me or my representative. <br /> 5p� t7n �ehct,if' o f <br /> APPLICANT NAME(PLEASE PRINT) D It J• SIGNATU <br /> ko <br /> TITLE: Cn TATS ID# <br /> L. 1� entAt e,i1 �St GA-�gq2(� <br /> Approved Sy Date Acecunting Office Processing Completed Dots �\ 5 D <br /> SITE MITIGATION - AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE R68EIR-P#: HECK# RECEIVED <br /> .s..,- _ n WK PLAN PE r <br /> 'G <br /> FEE .. g�U,�V \` Lti�f� t. s:✓.�5�. Dq�,t7v... �A3-8 � <br /> BY <br /> r <br />