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s <br /> San Jo 'quip County'EhvIV61imental Health Departmertt <br /> i DATE1E MASTER EILE'REC4RD�i4roRMA' TiON' MFR" 'GREEN FORM <br /> Q SITE,MITiGATIQN& LOP <br /> SHADP0A0FA5E0REHD1jsr—�I�Y OWNERIDg UNIT =.f . <br /> So37 <br /> OYYNER FILE:COMPLOZETHEFOLLOW/NG.PROPERTY OWNER INFoRmATION: ONECXIP OWNER CURHENTLYONFILF wITm EHO <br /> PROPERTY OWNER NAME �1 Z �. -OO --..-- . <br /> �Firs1 M! :ast_ •.PHaNE NUMBER' <br /> i <br /> I BUSINESS NAME.- s - s 1 - .... . "EM n-AODkas <br /> ConVer% 4 <br /> Lair'..a <br /> eZ,& can� ,Ca� <br /> I Owner HomeAddr6s' a " <br /> 7r 8 P..�Ku� <br /> p re as���� I;T�T� ZAP . <br /> k [q 9.IIS6 G <br /> Owner Malting Address <br /> I 71 Y o , 4 <br /> Mailing Address City- Q// -State. Zip .f <br /> CORPORATION INDIVIDUAL'❑ PARTNERSHIP❑.. - FED AGENCY[] -, 'OTHER.❑, - <br /> SITE MITIGATION ENYIROM IRWAL ASSCS$mc?4Y VOILUNTARY'dL:EANUP._WATER QUALITY_HW I.IPIEUNE INVESTIGATION_LOIS X <br /> I <br /> nCLL?yq tNyjj ACGOUNTID ;PR RO#'E AS aN rcMPLOYEE; LEADAOENOYEH, RWLiC$' UTSC`EPA <br /> 2,ZgSG S.: 35� D _ <br /> FACILITYFILE COMPLETE THEFOLLOWINGBUSINESS IFACILITY/SITE INFORmTION.' T <br /> Is this a NEW Business LOCATION not previously e6bulated Ily the'ENHlIiONMENTAL HEA;t.TH DEPARTMENT? 'YE5❑ -N() <br /> j <br /> Is this an EXISTING Business LOCATION but a NEW TYPE cif regula6ti 8usinesO ;YE5'❑ ?Nti'JK <br /> i' BUsiNESS/FAOILRYISiTE NAME.. , / ... - _ .-._ -Y - <br /> IC( . . .:. � <br /> 'SITEAbDRESS .. _. . _ - . - :'SURE* ausiWass PHONE <br /> Lot^ 209-5J7y- /SzZ <br /> CITY STAT£ `-ZIP <br /> 544 C, K�� CA �T52 a 9 . <br /> BDARD OF SUPERVISOR OISTMCT� -O L/ �LOOATIum CODE M1_ r 0! KEY7 <br /> Mailing Address NDIFFERENT..f6mFac1111yAddress Attention:orCarti Qf(opG vnaJj- <br /> Milli ingAddressCity STATE .ZIP <br /> 810 CODE APN g - `CuMMEttT _ <br /> ' <br /> 11 THIRD PARTY BILLING I NFD: COMOkedW 81111 9 Rarty is;a'ifferent from Prgpet ty Owner t7rFacllltjr Operator itieirti�ed a_hove. ! <br /> :BUSINESS NAME /I^.�Ch rpm Attention:orCare Of(apl/ona/f�CM15 pC 7 �0�7' <br /> MailingAddrwss , ±PNoNE .. <br /> rioso.. . . wt.;�... �to�K Ra . . .s.,,r4.. :rr_a �-: . ..; , <br /> CITY /t :STATE ZIP <br /> Rr-� <br /> ok^ (of`o�Ov � tr q$67.0 <br /> A('cpjJAITADUA for fees-.and charges OWNER. FACILtTWBUSINEss TWIRD PARTY BILLINGJF <br /> li BILLINC'AN11 COA1PLIANCF ACKNo%yLEnG361EN-i; I,the nniiersigned Apl lic:int,certify!hat1 am the Owt,:Opernror,orAnihnrizedAgent Of this'fiuslriess,.And 1 ac"dwic.dge-thai'.,aDJ��nMiTFees, <br /> lEvrTlES,Fivi7oRCFiirr.7CHfRGES andlot HoURLYCNARGES also_tinted n'Ith this operation win be billed to ine at the address identified above as-the,4CCorlyrADDR1?55 The this site. I also certify that <br /> All information provided on this Appncatian is true and eorrecr;and that all regulated activities will be perr6rmed.in actOrdancc with all applicable SAN JOAQUIN 4 OUta7N Ordinance Cades'andlpr <br /> Standards And STATE and/Or'FEDERAL Laws and Regulatint[S.AR the U1ltlerslgned O/l ner,'Operator,Ov agent Of the prati"Iocaled at the above,,fae]IitylSite addiCss�l h[rebV-'111tharlZe the iCICa3t.lil <br /> any and all"sults and euvimitmeninl assessment JgFwmttlou-to SAN JOAQUIh COUNTY ENVIRONMF1NTA1.HEALTH,I)EPARTMiaiNi=as soon,as,it is available_ ntid at ihe'same;time!it is <br /> proAded to me or my representative.' <br /> � I <br /> APPLICANT NAME(PLEASe PRINT) SrcMnTURi <br /> TITLE r TAX.IDV <br /> 4 >� I:f/ 16760 9I <br /> ` este Acoocnting OfRc©'Processing Complelad.6y ;Date,... <br /> Approved B , <br /> SITE MITIGATION AMOUNT PAI[!- .DATE OP PAYMENTPAYMEN7 TYPE -'RECEIPT to 1 `fCNECH - RECFJYED BY y - WOPE <br /> I Fee, <br /> Ib <br /> E + <br /> >V Y <br />