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San Jo-,,uin County Environmental Health De,rtment <br /> DATE i Q / I I I MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> l l f 9 SITE MITIGATION & LOP <br /> SHADEo AREAS FOR EHD USE ONLY OWNER ID# 1-73- <br /> V CASE# sR--.�b3 d Col.3 L�9 UNIT IV <br /> to 4� <br /> OWNER FILE:CCMPLETE TNEFOLLOW/NG PROPERTY OWNER/NFORMAT/ON.' CHECK IF OWNER CURREN rL Y ON FILE WRH E H D <br /> PROPERTY OWNER NAME ( } <br /> rust hit Last `PHONE NUMBER <br /> BUSINESS NAME � • �� � A _ � E-MAIL ADDRESS <br /> Owner Home Address r7/7 <br /> City STATE ZIP <br /> Owner Malling Address <br /> Mailing Address City Y'a C V ' I State ZJp 3 <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION _ENVIRONMENTAL ASSESSMEN VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> ±. f0ENCEHLAD FAOILITY ID# INV# ACC R#1 RO 1 . ' rQCB 'DISC <br /> A0 'p �lO� <br /> FACILITY FILE COMPLETE THEFOLLOWlNG BUSINESS I FACILITY 1 SITE AtFORMATloly: o�J <br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ �(J <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No ❑ <br /> EWw%E sWgatLm1S[TE NAME k L --6 `- ) <br /> V\/ M <br /> SITE ADDRESS [ /)_ , �. _ _�4—M ^ to r)G�,�-Tj - SUITE BUSINESS PHONE <br /> CITY l/ I V\ l /�t� STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 I <br /> Mailing Address ifDIFFERENTfrom Facility Address AttentJon:orCare Of(optional) ^ / <br /> Mailing Address City STATE LP <br /> SIC CODE <br /> JAPN 11 �I COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orfacility Operator identified above. <br /> BUSINESS NAME �in e- <br /> 0 GDS / aK ^��C Atientlon:orCare Of (optional) `�G �a -y( <br /> lel [.. (�C� Gi. I"L <br /> Mailing Address Frr 5a S f PHONE M --) 37/- <br /> 667 ( <br /> CITY .VQ►' r�r STATE _ �IIC ZIP ?LZ5— Ir> <br /> AcCounn'Aaanzw for fees and charges OWNER FACIL17YIE➢USINESS �' !THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACK:YOyyLFDGAIF.NT: 1,the undersigned applicant,certify that I am the Owner,Operator,or Awthurized Agent of this Business,and I acknowledge That all PERMIT FEES, <br /> PE,VALTIES,ENFORCER}EVTCHARGEs and/or HOURLY CHARGE.V associated with this operation will be billed to me at the address idenli Ged above as the;ICC'0t,Nr;tD0RESS for Ihu site. 1 1150 certify that <br /> all infornsalion provided an[his application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or VEDFILtl.Laws and Regulations. As the undersigned ovvoer,operator,or agent of the property located at the above facility/site address,1 hereby authorize the rele. of <br /> any and ail results and environmental assessment information to SAN JOAQUIN COt_Nnv ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is ave' blc and at thesonweNuidit is <br /> provided,...,,or my reprmentntive. <br /> APPLICANT NAME(PLEASE PRINT) /S /up�L/ SIGNATURE �j <br /> TITLE 5 L7. SCI Y— TAX ID# .+ O 337 <br /> 7 ?0 <br /> Approved By Date Accounting Cfilce Procesaing Completed By Date <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE:�3b.nU36,6�� �'`z.t1\\ ✓ I �12.`('Z (�,� 'Z�•5- <br /> A7 <br />