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San Joaquin County Environmental Health Department <br /> DarE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHa D @FOREHDUBEOmv OWNER IDN CASEN UNIT Ib <br /> OWNER FILE:CoMPLE7FrHEFOLLOW/Nc PROPER' YOWNER/NFORMArroN.• GMSGX,FOWNERCuaa[WnrovnLEwr EHD� <br /> LERTY OWNER NAME FirstLasrESSNAME - PHONE NUMBED75`1 '"L[S J -4eI is t <br /> E-MMLADDaEss <br /> er Home AddraSS (,i)n, dJ <br /> STATE!A ZIP <br /> Canner Mailing Address ,'l `JG �O <br /> Mailing Address City Y <br /> C,L.. amts �A zIP <j S 37 8 I <br /> CORPORAThNIP�, INDNIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION OMRONYSNTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_RW PIPELINE INVESTIOAitON_LOP_ <br /> 1, FACILITY IDN Isla AccouNT ID PRN/RON <br /> A%SIGNED EMPLOYEE LEAD AGENCY:EHD__RWQCa_DT$C_EPA <br /> _ <br /> FACILITYFILE COMF'LE7F rHEFOLLOWYNG BUSINESS/FACILITY/SITE INFORAMA770N.- <br /> Isthis aNEW BualnealL LOCATION not Previously regulated by the ENvlaoNMEHTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an Emma Sualra es LOCATION but NEW TYPE of regulated Business? YES ❑ No Ig <br /> BU4NE&NFAelL11YISU`E NAME <br /> SREAvomes <br /> SunrEa BUSINESS PHONE <br /> Cm .l 59-b55-�FH'6l <br /> STATE ZIP -^. <br /> -N 3�>LI <br /> BOpftDOF SUPERW60p D19TRICT LOCATION CODE NEY1 NEYZ <br /> Mailing Addrasa/YO/FFEAENrbom Faa 111yAddress <br /> Attention:arGro Of(opb'ofla/J <br /> Mailing Address City <br /> STATE ZlP <br /> SICCODE APNa <br /> COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different fromproperty Owner orFaci ity Operator idenlyfiedabove. <br /> \� BUBINE65 NAME }JC Q <br /> Ir cd rTQ t Attention:a-care of/aPbona9 Meiling Address Joke VJe'.cE..Address ('� <br /> Cm PHONE 55°l—(055 -q%\ Met�o�-fes <br /> STATE l A z" 13040 <br /> A(QPtlMlAgNW forfeesandcharges OWNER FACIUTY/BUSINESS L. THIRD PARTY BILLING <br /> BILLING C' A O 1,the undersigned Appliranl,aerMy mat 1 am the Oma <br /> NE ,DpvJWnr,or AUNnn;rd Agent of the Susinest and 1 ncknnwletlge Inez ail P£aun'P1TiS, <br /> NACT1,lE ('-ryf1/N(Y:MENT('HAMiEI'ynd/Or r'/OURLY r,%/A EI BEOClated WIMI d119 Up[raon WIg be MIINI t0 me Atthe]ddress Idendned above as Ilii.-i(YTIL'NTii/y12.U'{Or the Site. IaIsofertdf dial <br /> All information provided on this gPPUe.d.A is rove and earned;and dW t as eegulated]ctivima will be pert rmed in ueeorllanre with all.ppfenbl,SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards And$TATE andlor FEDERAI.L SAS and Regulatame. Ae dM LLnder;lEned Owner,OperBlUr,Or 8gfnt Of 61[prolRr,'IOrated]I lila abin'C fa[iliry/;IM BddreSi,I hereby OLLtllnr¢e Nle relem[of <br /> any end all Irodis and environmenNi assessment infe,nndon in SAN JOAQUIN COUNTY EN"RONMENTAI,HEALTH DEPARTMENT As soon As it is available and at me same time it is <br /> proside l W me m m.,reprtsenladve. <br /> APPLICANT NAME(PLEASE PRIM!) —70�^ SIGNATURE <br /> TITLEQ IL: (' TAX ID# <br /> rlCCt- t- 8E4 - 07,2.$8 C)C> <br /> ads Oad8 AUPRUNUn Dake Prooeealn Completed <br /> Ga e <br /> SITE MITIGATION AMOUNT PgID DATE OF PAYMENT PAYMENT TYPE RECEIPTS <br /> FEE:= G.- /b �Q O �� �b CHECHS RECEIVED BY WOPH PLAN PE <br /> P/lz- oo� i � s <br />