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San Joaquin County Environmental Health Department <br /> DATE 6MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE RTIGATION & LOP <br /> an100 CAU/ UNIT IV <br /> owmaR PILa:ComPLE7r rHeFouowNo PROPERTY OWNER lwoft4noow Chrary OWNER Cu uwayonnuprm EHO <br /> F�r:d Ml Last PH0448 Ntanett <br /> BUBM&I NAME 4-HA4 AooRsas <br /> c 17y of 5-rocro ,'1;' u a� t c us <br /> g Z S N e C Lj)4MDO s7• l ,&f 31 <br /> CRY BrAaA a <br /> owner WoOft Addws <br /> Ma&V Addrsas city Stats ZIP <br /> C WCAAnae❑ tieotwouAL❑ PAnrmer►s❑ Fm AW4CY❑ C�ntoe� <br /> arra AIri70 TWN_Mf406N EWTAL A9S8sa Mff_VOLW WARY Ct UXUP_WATM QUALM_KW►IMM DCMrl&AT*N_LOP <br /> fAcam Sf/ Iwre A000utT tD PR N RO/ [A;atoyt0EWWM ltAo Aottmor.[first._JlWQCa_OT60_,EPA r <br /> PACUMFM Ca1fIpLeTE7wFotoN9Y1Ki BUSINESS/FACIUTY/SITE AfvRW rAm.' <br /> rstllii`t wee Buil ass LoaAnow riot ww4ou wy rep a#wd by the E"ftohmaaAL*aOEPARTY HT1 Yea 13do <br /> Is this an EAMNO&Akw"Lowfosi but a NEW TyPt o/rep lobed Bus nr ? YES a, No ❑ <br /> eumxesa/FAcLiTy4n.NAME _ 7- <br /> Sym AooFg= + .7# auTE/ .SQ3*am <br /> GZ55/ <br /> Crrr SrArt <br /> o C/9 52oZ <br /> sow OF ei3OWNoOA Dtm7KT LOCATton Coos I wn <br /> Ue&V Addtw/'CVP"WWYrftw f**A"W AtttstOm wCwe O/IgDt W <br /> ° "@ 5 'T o or kt-1 �' '� za S ZD 2-_ <br /> 610 Coos APR/ Oaeatexr. <br /> ftaa PAtmr SuAm Wo Car»pK�OM K BNS Ptttgl b d0broN fiam Property Owner orFt> sty Operator/denHfl <br /> med above. <br /> eum fluor �2cw rs .A P-j,� tom+t-r,w Ea L- — - � orCwe 0r*dbndl Ic d.i u/r ►.t sti p�r <br /> MaIMp ado`." C o c-�- o Svc' 60 P, C17 rG 40 -o t i3 <br /> Crry "t^+Ltft COYLUC V aq C" I p STATE n Zs f J V I V <br /> Ax few end charQM OWNER FACIt1TYlBusrd S Ti RD PARTY B1LuNG <br /> . I,the oedmigned Applicant,certify that I ares the Ow ,Opavier,or AsvhorceJ Agew of this Business,and I adtnowiedge that ill PzLwT Fps, <br /> PL LnzS,E.NF09czwEvrCtiuGrs and/or HOURL 1CHARGES associated with this operation wW be billed to meat the address Ides dfltd above as the ACCot-n,IWl=for this cite_ I ilia certify that <br /> all information provided of this appikAtion is true and correct;and that all regulated activtties will be performed La accordnoce+tth AS app8cable SAX JOAQt,14 COLLA.n Ordhtaoce Codes and/or <br /> Staodards end STATE andlor FULZL.Laws and Regulations. As the sndersigned owner,operator,or agent of the property located at the above facilky,`ske address,I hereby sutbortm the rekr a of <br /> any and a➢resaits and enstroamentat assessment information to SAN JOAQM COUNTY F.VY1R0N1Nf YTAL HEALTH DEPARTNIL`7 as soon as It is avaihble and at the same time it is <br /> provided to me or my replwmUd►a <br /> r. <br /> P��cARrwur� K,--ry In/AL Ae atow„ut� <br /> TAx lag <br /> 00Sm <br /> am Mmwnm AMO%W PAW IMit CO rA"IENT PArrert Trrt Recur/ C"Sw/ ROCIrM sr 1YOtt7i Pum pl <br /> l <br />