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0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE7 1 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> "APE a POR ENO WN <br /> ONLY OER IDB CASE UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION. cxrx,eNNER ra cmxERnrm FRE wnx EHO� <br /> PROPERTY`ONMER NAME <br /> FIRST MI Lnsi PHONE NuMeER <br /> eYAIL bDREN <br /> BUBMEBe MINE <br /> / J"4(A(A! V✓TIF__ Ai C. <br /> OWNER HOME Acalwad <br /> Cm STATE ZIP <br /> OYMERMAUNOAUDNEBB C� -'r, �p <br /> MAILINGADDRE&II ( 'L STATE 7t)FD C_ <br /> IQ-J CURPORATION [I(NONIDUAI. ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑REIPOIee1BLE PARTY E]OFHES <br /> SITE MITIGATION _ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP—WATER QUALITY HW PIPELINE INVESTIGATION_ _LOP <br /> FACILm IDS /NVR ACCOUNT ID PRBIROR AWWEO EMPLOYEE LEAD AUENGY:EHD_RWQCB_DTSC_EPA_ <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? Yes ❑ NO cy <br /> IS THIS AN DUSTING PROJECT LOCATION,81.1r A NEW SCOPE OF WORK? YES No ❑ <br /> SUSINESBIFACILMI81TEMIRWECT NAME oNL <br /> 81TE bOREaSIPROJECT LOCATION SUMER SUSWEBSPHME <br /> STATE mGl336 <br /> 0OaRDUFSUPERV1Sdi DISIVICT (]3 LOCATION CODE 107 KEY1 KEY2 <br /> MARAUD ADMIEBB.IF DIFFEREAR FROM FACILITY ADDRESS ATTENTION:MCARE OF(OPTATRALf <br /> S ATE ZIP MAlRa AODREee Cm 3 0 3 LI <br /> UTN'fYA <br /> SICCGDe APNS cc�: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINEGI NAYS �/�e / (,/S /NL AT WIM::09CARE OFF OPF»xAL}LO.�E�' <br /> /✓tirl C7 S f <br /> PHONE <br /> Ip 2a6I4Y Y`0 <br /> Cm STATE LP 9 / <br /> /cOSE✓ILLS � "Tc <br /> ACCGUNr AODREASTO BENOFEEBANDCKAROES: OWNERO FACILITYIBUSINESSO THIRD PARTY BILL/ <br /> B G COMv C A DGW : 1.the uederaiened AppHeaal,ce Ify that 1 am the Oawer,Opermar,Amhoriul Apanr,or Respowak Parry sad I achnowledEe tbat all PawnF1,cs. <br /> PENALnES,ENkVRf P CHIN O anOw HounYCRA m MrKlated wilh Ibis pmjeet will be baled m me at the address Ideodned above as the ADCOTmTAmescT fw Hdr sits.1 elw reedfy that ILD <br /> Informed.provided m this eppdcadoa Is Ieue aM coe wG end that all reEWmed scdvldM wW be performed le accordance with all epplimble SAN JOAVUIN COUICI V ORDTHANB COM aedlw <br /> Srpxpn antl STATe andlw FEDEIUL/Armaetl ReGUunONb.As the undersigned Owner,OperPmr,Awhodwaf AVAL Ar ReW451ble Parry far the pmlwt looted above uoderfecWlylsite addreu,I <br /> berets eathorice the.11.1 of sSy sad at'Oulu,ream aed other eavlrmosenml asseasmeot infwmsdan to SAN JOAQUO CO ETrvmONNRNTAL[WLTN D"ARTMBIrrAt we m It Is avallable <br /> aDtl at the same time 11 Is provided to me or my"p,stesol!aSve. {/ I <br /> APPYCANT NAME(PLE WPRINT) Ct/'p/,j��//1✓� (Q(�f�� SIIWATU <br /> Ina AY 2 <br /> TITLE T <br /> f� - 'D��- 3 Z <br /> APFwOhp n, yah AtCU1MIMGDIMDE PRGCEMINO GOYPIErFD BY DATE <br /> SRE MRIOATION AYODMT PAID DAT[rR PAYMENT PAYYENTTVPE REOEIPTd CXECRB RECEIVED BY WO"=PE <br /> Fee:+ <br />