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San squin County Environmental Health9partment SIT,, <br /> DATE 7-117111 MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> SITE MITIGATION & LOP <br /> AHAD99 AREAS FOR END USE ONLY OWNER ID# CABE# UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOWING PROPERTY OWNER/NFORMA 7/ON.•�6 NN <br /> /� rl� G /�` CNECN/F OWNER CURRENrLYON F/LEW/TN EHD Ll <br /> 7BUSINM <br /> OWNER NAME (�/V -f,u,l CrtJ' ter_/ 57D <br /> First Ml Last PHONENUMBER <br /> NAME 1� E-MAILADDRESS <br /> me Address <br /> city <br /> STATE ZIP <br /> Owner Mailing Addreae <br /> (J JC.L/1/hd �'it.rfC 1300 <br /> Melling Address City <br /> CORPORATION INDIVIDUAL❑ PAR ❑ <br /> TNERSHIP FED AGENCY OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSEaSMEN7 X VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP_ <br /> FACILITY ID# INV# ACCOUNTID PRWRO# ASSIGNED EMPLOYEE LEAD AGENCY:EHDX—RWQCB_DTSC_EPA_ <br /> 16P <br /> FACILITYFILE COMPLETE THEFOLLOW/NG BUSINESSI FACILITY/SITE AfFORMATION' <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 /> BUSINEsSIFACILIIY/s1TE NAME (�i� / �G za I <br /> SITE ADDRESS / �O®vN^- t/v V(b <br /> J ( SUITE# BUSINESS PHONE <br /> Cm / <br /> STATE ZIP ^���V <br /> fi <br /> BOAROOFSUPERVISORDISTRICT LOCATION CODE Kert K/-�lEY2 <br /> Malting AdItreaa MOIFFERENTItems Fac0j,Adomea <br /> Attention:DrCare Of(opfANNr// <br /> Mailing Address City <br /> STATE ZIP <br /> SIC CODE APN# <br /> COMMENT: <br /> THIRD PARTY BILLING INFO: Camp/ete if Billing Party is different from Property Owner or-Facility Operator identified above. <br /> BUSINESS NAME MS <br /> Attention:wCare Of(oprlp/a/J 3 &3 3 r.OOOOZ <br /> Melling AdtlreeairO 11r r"1 t� /�O 9r� � 7 �s� <br /> L./JWX �(f// VV dN/ L.J\GL ! PHONE <br /> STATE mss„ ZIP q5 y 3 <br /> ACCOHATAaawl8Y for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLED MENT: L the undersigned Applicant,certify that 1 am the Owner,Operamc or Autheri¢ed Agent of this Business,end 1 acknowledge that all P£Fm/TF£eS, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLYCHAAGES associated with this operation will be billed tome at the address identified above as the ACGOUNTAHORESY for this site, I also certify that <br /> all information provided on this application is true end correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN 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 authori a 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 fime it is <br /> provided to me or my representafive. <br /> APPLICANT NAME(PLEASEPRINT) /(UVV�� ��(� QC�� SIGNATURE <br /> TITLE �'^/Q TAX IC# <br /> Approved By Data AnneunUng OMea proceeding Completed By Dale <br /> SITE MITIGATION ApMOUNTPAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# <br /> FEE:$Tk 7 RECEIVED BY WORK PLAN PE <br /> J575 7 az2 Iz �L�� 33 z �se, f'r ;z 1?5(--) <br />