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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> �� MASTER FILE RECORD INFORMATION IgMFR" GREEN FORM <br /> PATE 2 S�Zd�3 r� rI SITE MITIGATION&LOP <br /> !! OA ENO EEO OWNERIDI Jf 71 ( CARE SRO0`nT/ �q` UNIT IV <br /> OWNER FILE:COMPLETE PROPERTYOWNERI RESPONSIBLE PARTY INFORMATION; CxecR•YOxWE.a to cuaaExnravFXE wnx EHDEl <br /> PRoPeAry OWNER NAME � <br /> FIRST MI Lasi PHONE NutoEa <br /> EMAIL ADONEfO <br /> BDEMEaf NAME <br /> / ,Ga GG�W r/ArTE.t, rvG <br /> OWNER HOES AODREff <br /> Cm STATE m <br /> OWNERMAEJNGAWRESE G/� e� , I� eZ6 OU7- - <br /> MAILINGADwREEE CRY ( -/ T l/ /G G .J <br /> STATE <br /> � mO S-I <br /> MINrSiE,Q <br /> Ipd CORPORATION ❑INDNIEUAL ❑Pa rTNERNIP ❑GOVERNMEYrr AGENCY ❑REEPDXIMLE PARTY ❑Orii R <br /> $ITE MITIGATION_ENVIRONMENTAL ASSESSMENT X—VOLUNTARY CLEANUP_WATER QUALITY HW PIPELINE INVESTIGATION_LOP <br /> FACILM IDI INVAACCOUNT ID P ROI ASNONED EMPLOYEE LE AO ACENCY:END�RWGCB_DTSO_EPA_ <br /> 18 3 31 FS-1 o i Iie, <br /> FACILITY FILE:COMPLETE BUSINESS I SITEI PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YE9 ❑ Na <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORN? Y!5 NO ❑ <br /> BUEINESWFACMITYISRFRROJECT NAME VAS, IMG <br /> BRE ApORESer PxoJECrLouTlOfl Sumo BUSINESS PNOtis <br /> IMP /2o/m <br /> STATECm I <br /> m <br /> CA <br /> �S 336 <br /> BWROCFBUPMiW DRIWCT �3 LacArION RODE Q� KEYE KEr2 <br /> MAIIJNGADDRESf,IPOIFFEIIEXTFROMFACL ADDREff ATTENTION:WCAREOF(i0PTAW4L) <br /> 55 r AIL <br /> MA .dan AOCRESS CDY �A� m3o 3LY <br /> L/kN'llR <br /> sic cow APNI caMEEx: <br /> TNI RO PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NATEATTENTION:CIPCARE OF(MTxkLAL}LO e✓ti <br /> 2CIQar3- uS (N c c riyLr - nEti t <br /> MA"o ADDRESS PHONE <br /> r0 2oGKY ro <br /> LP <br /> CRY STATE 6/ <br /> OSE dIL.t.6 <br /> ACOOUNTAODRESS TO SEND FEES AND CHARGES: OWNERO FACILITYBUSINESSO THIRD PARTY BILLI <br /> B G C LIAHCE ACI 0u 1raG111EN: 11 the uadeOigoed Applimm,Certify that 1 em the Onner,Opermar,Aurhanud Agent,or Responsible Party and I acknowledge flet all Peawr FEES, <br /> PEKGLTIEs,EMOeCIneaNl CHARGES andlor IfoOa6v CaARcas usacttad will[his project will be luted to me at the add[esf ideaSRetl atone ae the ACCCWIJADOFEST rm thh sIN.1 also certify that all <br /> information provided on this epplicadan b true anal corremt and that all regWawd acavidar will be perrormed in ecordvoce with all applimble,SAN JOAQM COLM Oaar Am CODES amus <br /> SrANDA andnknsadlm FEDERALLawsand RSOI ONS.As the undersigned Onter,OPeramr,AuthoxudAgenl,or ResPnalble Pally forthe projeet located above under feegitylsiarsabITss,l <br /> hereby authorize the release of any Sad all rmWh,report,and caber enNroomeotel eesesament IMormetlao to SaN JOAQM COurrIY ENVmON,YtENTAL RlALrH DXPARTTtaXT u tone u it t available <br /> andet the sometimeIt n provided tome"my rVraenttive, <br /> APPLICANT NAME(PIERRE PAINT) �f�2/,S%�'/fC�- "1�(Ov. � SIMATURri._r,,.--.: <br /> TIME / TAX ID I <br /> AreROYF�b GATE ACapMInxODtlef.E PROCESWrGCtNMtEIFSm DATE I3 <br /> BITE MRITUTIOX AMWNTPAIO DATE aF-PfAYYENT PAYME/NSTTTYYPE RECENT/ CHECK III RECEIVED BY WGNI�� <br />