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San Joaquin County Environmental Health Department <br /> DATC 1/Zq/jj MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> 0WAX31110' °"`' s o UNIT IV <br /> OMVN1tJtPiLs.CaMLmnwFouowrn+ePROPERTY OWNER lmcoawArAw. c,TorFOWNER CuNtwnymmrwraBHO � <br /> fust <br /> All Last PA M[NNIMt <br /> NAtr 6-VAL Amte>ae <br /> G 5 O ,.�. <br /> ok~Now A*"w q?-5 N • E.L. DOMPO ST • � 31 <br /> 5 Tomsk To AJ 6TATI zr 9 5 20 Z— <br /> .d�letletMlewl�Aaftre�e <br /> M Wk*Address Gft teo.a ap <br /> CORPORATION❑ Mfodmuft❑ PMIMMItIr Peo Amour❑ of,tel <br /> Sm QARfaATTON_1w4wAte ofrAL Aaaerr_voLup"m f CLomw_BAIT=QutAuff_wa Prins UIVRtiT1SAT m_ <br /> PAOLM b• MM <br /> IAOMWO AtarM Mo 511FLO mlpb9 ��nllltft~ <br /> 5°i33 <br /> Flown R1f PM Cowittn8 rwFcao*x fo BUSINESS/FACILITY/SITE#*wave 7 o w <br /> Is Mw 4 NL1 vlftM ww L60PAOM wt P 1f by the&l4VMM l g_"ULW DEPAR MeM Yes ❑ No <br /> Is this an MosTINO Suoskow LOCATION but a NON TYPE of reptlyl»d BuslflNta9 YES No ❑ <br /> eUtlMf WFAC%.A-dB.1w. c, T <br /> SfiTlAoomm 730 F oN . PN# co 2- Bu04UPHM <br /> cO,t S Ta o NStAW n.g5 2A 2-- <br /> "Near MwhomOl im Fill x" <br /> ii«.'r> e,rr_inawn �Z$ Al•Et.Lb X T, Aa.r>tion tarcare 0/(gor4tttttep• TTY l.JA[X <br /> M 0 g Ad*ws Car STo76 AJ 5 2 <br /> aoam APN# e�a.fftert� <br /> 1WMD PAIIW 2LU"ft" H BN P b dffer* t Abm Ori or A*19 end abolre <br /> __ . Atlu,eorc anGia'�fopabi►,.� :,_ . ; ._ .. <br /> 2awnj a t...� 4'�a1.�wEtt�.. ,�o l v fzr.ISti ab' <br /> ti N"Addfeee los-,40 w o 1 Te Q o GV'— R-o4 o J�vt too PHONE <br /> 44 L1-01 t-3 <br /> CITY 9►N(,t+o C0 tt&ovs1G+, R slob o HTATt C, v RS-bio <br /> fbrfen end ehwgn OWNER FAcum/Buamm THIRD PAJm Bum <br /> . I,the andersiped Applicant,certify that I am the Owns,OP~,or Awhoresd Apaw of thio Basinm and 1 sclow"kdZe that alI PrawrFEST, <br /> PFXUY=ZYMACEMewrCRueat aad/er AotretrCauters aaodated wit►thb operation nU1 be billed to me at the address ideadfled&bow as the for this site,I she ca tlfy that <br /> all informadon provided ae this appBntima is dna and correct;and that aB reolawd acdvkies wtB be performed is accordance wkh aU appticabk SAN JOAQurr COUNTY Ordhuace Codes and/or <br /> Standards and STATE Lad/or FEDLu.Laws and Regalatba.As the andmlened owner,operator,or Mew*(Me Property tinted a1 the above kcilky/sits address I hereby Authorize the rekasc qf <br /> any and sO maks and etvtromwevoW assessment Informndon to SAN JOAQULY COUNTY B.` IRONS IUML HEALTH DEPARTMENT as soon u It Is avaikbic sad of the same time it <br /> provided to me or My repeaaa6htlrt <br /> WA 1 Ke <br /> 17'. <br /> q a0�3� <br /> �. <br /> NftDTPAYT! PA"Off Tl" Rscsn/row" I <br /> iadt <br /> TMTTL <br /> Ciel cst t ftetofeNe fh <br /> t <br />