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*artment <br /> sR (0seFs/�7San Joaquin County Environmental Health $R 63cc0 f( <br /> DATE II— Ti— �/ MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> L/ I 60 SITE MITIGATION&LOP <br /> SHADED AREAS FOR END usEONL OWNER ID# I�S?3 CASE# `n UOf 1 J97 UNIT IV <br /> OWNER FI LE:COMPLETE THE FOLLOWING PROPIERTY OWN ER/NFORMA T/ON:J'r" CNEOXSOWNER CueRENnrowF1LEwrrN EHD� <br /> PROPERTY OWNER NAME <br /> First MI Last PHONE NUMBER <br /> BUSINESS NAME / �r / E-MAIL ADDRESS <br /> i l✓L /AVPS�Orf Glo /iCarnt 117ve4r#a••S <br /> Owner Home Address <br /> !26 fde%n /Jve• <br /> city <br /> s , CA YSo3a STATE <br /> Los C4 ySa3o <br /> Owner Meiling Address <br /> Meiling Addreae City State Z:IP <br /> CORPOPATION❑ INDNIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILItt ID If INv# JAccou�D P%#I Oft As11 �oNEO E DYES LEAD AOENCY:EHITRWQCB�DTSC_EPA <br /> FACILITY FILE COMPLETE THEFOLLOWNG BUSINESTS/FACILITY/l/S_ICTl:E fNFORMA noN., <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ �� <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESstFACILRY/Sf1E NAME I\V" QfAnIC f"' <br /> BRE ADORE89 � I a � I� SURE# BUSINESS PHONE — <br /> CmTX^ N 1•"'I �–L] 21P gs3'17 �t <br /> SOARDOFSUPERVISORDISTRICT T <br /> LOCATKINCODE Kul KEY2 <br /> Meiling Address KO/FFERENTfrom Facility Address Attention:orCare Of fbpVaax/J <br /> Mailing Address City STATE LP <br /> SIC CODE APN# CaMMENT: <br /> zf,� -tic0- 3 i <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is yd�i�ffe/r'en�twfr1omProperty Owner or Facility Operator identified above. <br /> Bustmess NAME /G»�f[U �1S.rA�r�yr�I• l�r""r/ A nibn:orCare Of,tO NONR/f <br /> Mailing Address PHONE <br /> 2t,2 1/a/ /. «vin P mfr. Eloo 2oti- S'd3-Cfr/o <br /> CM S�cri'frM STATEZIP <br /> // fs.20L <br /> AfffiQLAg�OORES.S for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,rerfify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PE %HT FEES, <br /> fuaY TtEs,En'FoRcevExTCN.4R ei and/or Hotscr CR4RGEsassociated with this operation will be billed tome at the address Identified above as theACConTADDRRSS for this site. 1 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 COUNTY 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,l 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. C <br /> APPLICANT NAME(PLEASE PRINt) Igo_4 ,i«j f,e4l SIaNAruRE���r�La_/� <br /> TAX ID# <br /> TITLE <br /> UCG,lwv rE <br /> Approved By Date Accounting Once Processing Completed BY f I Dale <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVE08Y WORKKPI.ANPE <br /> FEE:$ 27 I d) <br />