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• • a <br /> R E �t'E <br /> San Joaquin County Environmental Health Department APR 12 2013 <br /> MASTER FILE RECORD INFORMATION"MFR" GR�IPORII <br /> DATE �j ;� t , _ .., <br /> - t SITE NIiT1G' �eflbP -_.�� <br /> � \p4 <br /> -- As -•roe END • ONLY Dwxm IDO CABs$ UNITI Y <br /> oWNERFILE:COOTPLETErNEFOLLowNePROPERTYOWNERINFORMArIoN' CmmrwOWNER CuouE rmnixiyfneEHD� <br /> PeQPPmYO~NAME <br /> Frst MI Last Pe ENa <br /> Ba.wPJts NAam (�o�i'�'co wk 0(Ii5Q.lz --- EiMILADtmess <br /> Owner Name Addrm <br /> City sTAm LP <br /> Owner Mailing Addrre L#,ke Dr1V-c <br /> Mailing Address City \S S %,j C, <br /> C1 - "an A z* <br /> Caarosanoxc] 1NDMc11I,El PMfN9MwP❑ FEaAB9XN❑ CTHM[I <br /> arris MRIOanON_ENwRON=NfAL ASSBSWBM_VOLDNTARY CtaAidur_WATER QUALITY—M PIPELINE INYWfMTION_LOP <br /> FAOIIITY IDO INvO AQcGuIn ID PROIROO Aswaaec ErrrooYEe LEAD Aaewne:EHD4—RWQOB_.DISC_EPA_ <br /> FACILITY FILE COMPLErETHEFoccowNC BUSINESS FACILITY SITE INFORMATION., <br /> IS this a NM Business LOCATION not Previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Ya [I No Q- <br /> Is this an ExwnNO Business LOCATION but a NEWTYPE of regulated Business? Yrs ❑ No L3 <br /> BHNNF2Mleaci likiSNA/Tres ' ^. <br /> StreAooesis I IV I lV L. r'I - sump Buwease PIIDIIE <br /> /3 YVI VMC t' L-.[/l V1:L <br /> CITY —. Seen Lr <br /> BoumtX•8w ees Dterxcr LorATNN CODE KEY1 KEYL <br /> Mailing Address f/DRFERENrhom FicWAOHrm Attention:wCara Of(opiete W) <br /> Melling Address City STATE LP <br /> SIC CooE APN/ Cam®fr. <br /> TNIRD PARTY BILLING INFO: Comphb ff Billing P h dHl rwgfr=Property Owner orFacllity Operator lden~above. <br /> BuwNEss NAre i� I Attention:wCare Of(01000,W)) <br /> � ��n L(7.As <br /> Mailing Ada... �Y >4dr� S�� t. 25o PEg9 �i <br /> Cm t V I r w STATE ZIP <br /> AamautrApAEEAs for fees and charges OWNER FAciuTY1BUSINESS THIRD PARTY BILL!71 <br /> a1tA ING AND COMPLIAN[E'AIXNOWLEOGMEM: L the uotlertirned Appa[Jat,llydfy Ihet 1 am Me fewer,0[,'lrmOr,nr AYIAOrI!!d ABAII of Ibx 14uiatwLatl 1➢Clmowlldee Hut all PEMIII'F£Er, <br /> PENALfIF9,ENF0ACEamNTCNAAG6and/or RODRLYCI ,Uassociated with thu operationwill Ie hUled In meat the address identified above u intA"nWAnaR£Sc far Mir rite I Wo certify that <br /> Eli infonsatim provided no this application's true and eorrect;sad Mat all reEWand aeMitier will tK plrf..W in areerdaore with as aPIU.We SAN JOAQUIN COten Y Ord ioavice Codes and/or <br /> Sbndards and STATE mdlor hEDsn• Wws and Reeuhtbm. At Me eaderstlmM owner,openror,or agmtof Me property looted at the abuse besity/rite address,l hereby authorm Ha release of <br /> any and W rraWa and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL NEALTN DEPARTMENT as soon u it is available and at the ome t®e it it <br /> provided to net or my repreeeoft a (^�1 <br /> &APPLICANT NAME(PLEAeE PRINT) �Q�"QM1� V EBgeAT1IAE �i <br /> TIRE TAX ID 9 <br /> Ser�or L�O`O iS� <br /> tOsla Gilles Dab <br /> TION ASCINiTPrdo Dare uP PAYMENT PAYMVRME Rem"" CHE"0 RaoeveoaY WoeX PMN PE <br /> J7S L�-IZ 13 C�CPrC - _,-. t� Qna.c�� X950 <br />