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1` F <br /> San J(N..4uiD% <br /> n County Environmental Health ,llsIlettment <br /> DATE <br /> A <br /> MASTER FILE RECdRO INFORMATION "MFR"' OREENFORM <br /> SITE MITIGATION&LOP <br /> s <br /> UN <br /> IDS., IV <br /> OIIINIII'IDIM: DAslii :' ,; <br /> OWNER FILE:COMPLEMESPONSIBLE PARTY AfFdRMAT/ON• OnEcrrrr OWNER 0umEMTLrQNFREH7rrf EHO 0 <br /> PROPERTY OWNER NAME Y 1 GF- !G C G it 2 1 <br /> l First 1 Ml Last IPJHONENumsEit b 7 <br /> BUSINESS NAME / :ADDREea Ya f e I/V•c o�+ <br /> Owner Home Address <br /> City STATE ZIP <br /> Owner Mailing Address / 3� V 1 y <br /> ge <br /> ro •f'l_1�.J <br /> Malllnp Addse City I(II L (J` „ 1 j N, _ Btsla /1 ,t 21p n <br /> ❑CORPORATION (!(,t❑�IND(nnMDUAL ©PARTHERBHiP GOVERNMENT AGENCY RESPONSIBLEPARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY <br /> t�HW PIPELINE INVESTIGATION_LOP <br /> �FAOILItYID/[ *V4, <br /> FACILITY FILE: CoMPLETE BUSINESS I SITE/PROJECT lwoRMAT/Om <br /> Is this a NEW Project LOCATION not previously regulated by the EwRONMEikITAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Project LOCATION but a/NEW SCOPE OF WORV YES�?— No ❑ <br /> BUSINEaSIFACILITYISITEIPROJECT NAME �n r n•/YI /� ! <br /> SITE AtIoRESS I PROJECT LOCATION v 1W,v, i W V(Q r 1A� �� r SUITE# BUSINESS PHONE <br /> CITY /� UGV� it STATE„ ZIP 95240 .IJ {O <br /> #uP[IlWuioi4t�lsitaor s $ I I.LopAtloN000rr' . ` liar{ "k x �`KIe1ft':`r 1 a <br /> Mailing Address ff01FFEREAIrhvm F&olll ,Addblsas Attenllan:orCare Of(optloasq <br /> MaNingAddreaaClty � /J BTATe,e A ZIP 9 <br /> x <br /> THIRD PARTY BILLING INFO:. Completelf Billing Party Is different fromPEerty Owner or Res onsible Pa Identlfredabove. <br /> BU INEssNAME Attention:orcareOf (opflowl) <br /> Mailing Address PHONE <br /> i <br /> CITY STATE ZIP { <br /> Aaaw rrAeaxr:ss for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> Ill LIANC AND,GompmA\cE.%cK.No1Si.Ern;%iFwr: 1,Ihv undersignett Applicant,certify that 111111 the thefrer,Operator,arrllmrl e(►dge)il,or Responsible Parr and I ncknowredge That all PF.'rtun'FeF:v, <br /> PFA:aLFrFas,li,vrnHc'F;trn'r Cn.lnGt:'.v nndlor NnI'NL I'[.'el1RrlFs nxsociated vith this projrcl will lie billed to me at the addreSR idenlil lyd above as Ihefor This Sale, t 91%o Certify(hal all <br /> ioformattoc provided on this application is true and correct;and that all regulated activities it Ill be performed in accordance Mill all applicable 51R.Io:1QGtt Gntwl s Ordinnnre[.`odes andlor <br /> Slafitlard%and STATE andfur I'ED£RAI.Lans and Regulations. As lite undemigned Omter,Operator,Authorized Agent,or Hrspensible Party for the prnjccl Ioralelt above under TnciirlyAlle nddress,1 <br /> hereby aulborirr lite release of any and all resal1%reports,and other rnvirmnncnDtl assessment Infolrnntion to SAN.I(IAQ(II I('01\"I T`I{?\ No N' t[F: TII DEPARTNTNT av soon as it <br /> is available and al the same time it is provided In me or my rritreseninlive. <br /> SIGNATURE <br /> APPLICANT NAME(PLEASE PRINT) i t jL • <br /> C.S v <br /> TITLEI TAX ID# <br /> o vv; tlr(��I' ( -- ('I Z(o <br /> Approved B Dab Accounting Office firoceealns Comptated By I Data l <br /> BRI!MmGATion AMOUNT PAID DATe OF PAYMENT PAYMENTTYPE kRECEtPT R - CHIDK/ REOEIVED_ BT Er" 4 i <br /> FEE: �s a <br />