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San Joa 'n County Environmental Health De rtlment <br /> DATE [)-o <br /> - \..-L- I MASTER FILE RECORD INFORMATION "MFR'' GREENI=ORM <br /> SITE MITIGATION <br /> ■■& LOP <br /> SHADED AREAB Port EHD USE ONLY OWNER WO CASE# UNI ■TIV <br /> OWNER FILE XOMPLMrHEFOLLOMW PROPERTY OWNER INFORMA77om CHEcKIF OW/NNrER CVRREARLroNFlLEKwN E H 0 <br /> PROPERTY OWNER NAME MSS Qe..E Ir��e (. (M �3 V —3 <br /> "ll First Mf Last PHONE NUMaER r <br /> BUsmess NAMEt. EaNNLADDRESS <br /> Vv fl�lfe G, <br /> Owner Home Address <br /> CityL STATE zip t C,4 <br /> Owner Mailing Address <br /> S C-t.L'l 2 <br /> Mailing Address City I t [ t 1 state I 71p t <br /> CORPORATiO491 INDIVIDUAL❑ PARTNERSHIP❑ FEO AGENCY❑ OTHER❑ <br /> SITE Mme riaN_WmRoNmENrAL AsswslilHNr_VOL UNTARY CLowup—WATER QuALrry�KW PIPEuNE IwasneATioN_LOP <br /> FACILITY IDS INV# ACCOUNT IQ PRO/ROS ASSIGNED EMPLOYEE LEAD AGENtiY;END_RWQCB�,,,QTSG-._._,Et'.l'�„;_ <br /> FACILITY FILE ComPL=,rHEFoLLowA(G BUSINESS/FACILITY/SITE INFORnfw7ow <br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes © NC,,K <br /> Is this an E)USTING Business LOCATION but a NEW TYPE of regulatedd Business? YES� No ❑ <br /> 0US1Ness*ACtLny1SfrE1'IAME. % <br /> SrrEADORESe l� (` SUITE# BUSINESS PHONE <br /> CITY STATE LP <br /> 9 z <br /> BOARD OF SUPERVISOR DISTRICT LOCAmm CODE KEY'I KEPI <br /> Mailing AddressYDWERWrfram FavilWAddross AdenUon:orCare Of(apbbewl) <br /> Mailing Address City C STATE ZIP t i <br /> t <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INP01. Complete if Billing Party is different from Property Owner or Facility Operator identibed above. <br /> BusittEss NAME C, Attention:orCare Of(opt5bfud) <br /> twp ��1Ji�Inuv� �C. <br /> Mailing Addrew PHONE <br /> CITY STATE 7JP <br /> C,,4- r-T--D i 5 <br /> ACt=MfZAdt2BAea for fees and charges OWNER FACILITY/13UsiNEss THIRD PARTY BILLING <br /> BILLING ANID COMPLIANcR ACKNOWLEDGMFWF: I,the undersigned Applicant certify that I ane the Owner,Operaier,orAuthorited Agenf of this Business,and i aclasowledge that all PERmrir FEES, <br /> PFNAi Tif-s,F1vPoRCEmF.NTC;L4RC,F;c andlor HouRLYC.NAR(iF.S associated with this operation will be billed to me at the address identified above as the AlMuATADIDRF_Ct for this site, I also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN 3OAQUIN C01.INTY Ordinance Codes and/or <br /> Standards and STAIR and/or FFDRRAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at it}[ he facilitsrxite add{rossrj hereby authorize the releaseaf <br /> any and all results and environmental assessment information to SAN dOAQIITN Ct7 NTY ENVIRONMENTAL Hty1LTH DEP RT. as ryTtin 99-1 is avtaitabte and at.lbe same time it is <br /> provided to me or[try representative, <br /> t/ <br /> APPLICANT NAME(PLEASE PRINT) L4^�D.�(`� < � SIGNATURE <br /> TITLETAX I D# <br /> ,r-VC 2S <br /> Approved 13y• —_ Date Accounting Office Pre,ceeaing Complatad all Da _ <br /> SITE MITIGATION AMOUNT PAto DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECKS RECEIVED BYL'/ WORK PLAN PE: <br /> FEE:;• <br />