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San Jol cin County Environmental Health ar, rtment <br /> PATEl ✓ � MASTER FILE RECORD INFORMATION "MFR" aREEN I:oRM <br /> SITE MITIGATION&LOP <br /> $HItO)_n AREA!1TR FSHD Y8E ONLY 1 { - UNIT f V <br /> S . <br /> OWNER FILE:COMPLETE WWWRESPONSIBLE PARTY INFORMAyrom, CHECKIF OWNER OURRENrLV 0M.I&EWlrN END <br /> 9 PROPERTY OWNER NAME 5 (r [ rte /J� p) G Q n2 I <br /> Firs L MI Last 1PHON/ENuMBBER 4 7 <br /> SUSINESaNAME /f E-MNLAomsa . <br /> Owner Hone Address <br /> I <br /> City STATE ZIp <br /> Owner MaliMp Address <br /> (Q�5 vJevf T6,d f <br /> Malllrtg Address City f f state h , ZIP ^ 7 O <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP (3 GOVERNMENT AGEN'V RESPONSIBLE PAR" ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL A88E89MENT_VOLUNTARY CLEANUP_WATER QUALITY T HW PIPELINE INVES'rlflATIQN LOP <br /> #F/IaLITY.l6i IyVR /10oDUyjFID .+PR,N1ROi1Fq <br /> baarp� Ldp _i�l <br /> r- <br /> • :r <br /> FACILITY FILE: COMPLETE BUSINESS SITEI PROJECT 1AW&MA770lli:' <br /> Is this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? yes ❑ No <br /> Is this an E1f18TINO Project LOCATION but a NEW SCOPE OF WORK? YES Nty ❑ <br /> SUSINESSIFAciurYlS1TElPRDAECT NAME Vat f e v (e 4( C <br /> SITE ADDRESS I P/tomm LowtoN ` MO <br /> ' f _ W e,r, 1 _..e ��f SUITE A Emma PHONE 5 <br /> CITY 1 YC „L.,J�,N'y�_` I {/"`t+t/'~ STATE„ ZIP % O <br /> ',f G <br /> MEllinp Addrsa s/f01MERENrfmm FaelJltyAddvesI Attention:orCere Of(gpUbasJ <br /> QevO r G<,I�,►i° �, <br /> E Zip II <br /> Mailing Address City #L_ � /J F STAT /1 <br /> �>sldpjapn,. x ���"�F,`� it . ,. '� �- ="`w. �• ✓°:;:a` r... .. -, �� �� v Nps: <br /> THIRo PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orRes onslble Party identiried shove. <br /> 1 BUSINESS NAME Attentlon:or Care Or(apMm o <br /> h <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> AccauNrAfor fees and charges OWNER FACILITY16USINESS THIRD PARTY BILLING <br /> ' 111I.t.lNa AND C(IMPLIAsct: 1,file undersigned Applicant,certify that I am the(hvser,Operater,.4 1hor1: l Agent,ar RespermiGfe Por(r and 1 acknowledge that all P}:RIRt'!•'r'r_c, <br /> PF'wgl.rsF:C,l:n'FnRe xsrr,`,'r(yr.IRrrxc nndlor!lnrxay('uaRGas assar•imed with this project will Im billed to me at the address iticntiCird nbo%e as the:uc'rr}asrAbfor this site. I also certify that nil <br /> information proridnl on Illh application is tnm and correct;and that aR regulalctl aclisitirs will be perforated in accordance%ith ail applicable SAN JOAQUIN COVNIV Ordinance Codes nmNor <br /> Standard.and S AIE andfar FEDERAL I.aws anti Regulntiuns.-As tire undersigned Owner,Qperntoi',Authorised Agent,ar Responsible Party for the project Incnterl ahorc under facility/site address,I <br /> hereby authorise the release itrany and all mulls,reports,and n1her casironnenlnl assessment Inforaaalinn to SAN,IOAQI Ihf C01;,\T}'4:N►'I )YAllf 'L\I.11F:, 'PEI DMIAR'rNIFA'ns soon as it <br /> is available anti nt the same time it is pmtided to rile ur my rri resemative. <br /> APPLICANT NAME(PLEASEPRINT) ! �! `{1t, �n � � �V SIGNATURE (� <br /> / TaxiDla (� 1 <br /> TITLE ��Gt frl�urtCn��C� WvVI l V'tft ZL�5� <br /> A sd Data Acewnting O1Rcs Pioasssing CornploWd Gy Data <br /> 8nC MITIGATION AMOUNT PoAo PATE OFrAYYENT PAYMENT TYl'}E REOIIPT 1 ,CNl01t/ REOdIVLD BY TR <br /> fYoR�I PLAN.PE, r <br /> FEE:JE i <br /> N t; <br /> l <br />