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San Joatin County Environmental Health Depipment GREENFORM <br /> DATE I I I O I u MASTER FILE RECORD INFORMATION MFR SITE MITIGATION&LOP <br /> h —A�rOS HB ONLY OWNER IDf <br /> CASES UNIT IV <br /> CN,.,OWNER CUHRExrtravm.Ewmf EHD <br /> OMERFILE.00MPLr�mEFOLLowuvcPROPERTYOWNERNvFvn�arroN: ( ) <br /> PROPER'IYUV1tIHi NAPE PNONENIINBER <br /> Fist MI �� E-0WLADORFBa <br /> 7 In <br /> BIMw63s NNLE 5 i e� L xlkn . --t t.✓e. <br /> ownerHolne Address �. . J� 7 <br /> � LP9�Z V J <br /> Owner Mailing Address –� 0 ,C �'x Z 16 C�/Y•GtF z–�y� <br /> Melling Address CRY y 0 1 <br /> ( z� <br /> iNOIwOUAL❑ PARTNERSHIP❑ <br /> FWAGENOY❑ oma+❑ <br /> CORPOMTNNI� <br /> Srm MmaATwN_ <br /> ENV/RONMlH7AL ASRUfSMUNT_VOWNrARY CLNWUP._WAYIRQUALrrY_NW PIPWNL INVE TIOAYION_LOP_ <br /> FAD_ lDf INvf ACCOUNT ID -PI�OE, Ass10NED EMPLOYEE LEAD AGENCY:EHD—RWCCe._.DT9C_EPA— <br /> AP��o3bg13 <br /> FACILITY FILE COMPLETE THEFOLLOW7NG BUSINESS I FACILITY I SITE INFORM477ON: YES El No <br /> is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMF•NT4 <br /> YES ❑ No ❑ <br /> is this an EXISTING Business LOCATION flute NEW TypE of reguleted BB11111,85? C� <br /> BuslNEsaIFACILITY/SITENme -t ex r !"1(ALk VGVS <br /> VVp � p �.T ,P $UIIEf &1SINESB PHONE <br /> IIE <br /> SAODAESS -7 't s+ 6A (.L I�� STATEcw-Lp <br /> CIrY S'-�nr \C�k-lbN-- 9SZo�- 331J <br /> BOAILOOFSUPERwSOR DIaTWCT LOCfsBDN CODE <br /> KErt KEYR <br /> ARerdlom orGsre Of(OP&O"el7 <br /> ME ill Address tDFFERFVT6 F—MlyAddresr <br /> STATE ZIP <br /> Malibsg Addrms CRY <br /> SR/CODE <br /> APNf COMMFM: <br /> is different from Property Owner orFacllity Operator identified above. <br /> TNIRD PARTY BILLING INFO: Complete if BNling Party Attention:orcare or 1OPEOW <br /> BUslNMNAME pp P l\ \T Jt –7 SLG I-yv, <br /> Mailing Address V I S1/tGwV CtiJ PIT 1N I – -7—�IX <br /> STATE GA ZJP q <br /> Clry <br /> � AOQR6gA'TOrreBe and dii9(gB8 OWNER <br /> FACILITYIBUSINESS THIRD PARTY BILLING <br /> _-____— <br /> B N N COM 1 NCR\CNNOWLEDGMEW; 1,the umlemigned Applicant,ettTiry that I em 0e!Tuna'•ODgwor.or Autharized Ae tti of this Business.and 1 acknowledge Mat ail PERM/T EES, <br /> pE LU,S,EHtT1ECHMENYCHAE aced/or I(OHRLYCHa Et assort d hstevu reg will be performed in Seco Aaneeawuh all applieable S��QUIN CO(KF`Ord"mance Codas and/or <br /> rater,ora t of the properly beefed at Me above farsity/site addrev,I hereby authorize the release of <br /> ail information provhlal^a thu ap AL Lawn u true and final F <br /> Standardb and STATE llnd/or emoon (Laws end,mfo Nona t the JOAQUI OW net,ops agent <br /> any and an resole and enviranmmMl assessment information to SAN.IOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH OEPA�1F.Mf as"^°°%S a Is availa�°and at'he s^me Hme it ss <br /> provided to me or my representative SIGNATUM <br /> APPLICANTNAME(PLEASEPRINT) k)rNV\\C,� 1 ICIt+A <br /> TAX ID# <br /> TITLE �.-u C}Cu�L7 i <br /> oma S o <br /> Acmat OISPe Prooaeaine Completed BY - <br /> B Oat° IRECEF ED BY WORN PLAN PE <br /> SITE NIMOATION AMOUNTPAID DATE OF AYIN PAType <br /> RECEITTf / / <br /> FM111 �fO' /I �D <br />