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San Joaquin County Environmental Health Department <br /> DATE 12_ 2-- 1 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> (� SITE MITIGATION& LOP <br /> SHADED AREAS FOR EMD USE ONLY OWNER ID# z�,S>�, CASE t�.�1 Jo 6 3 9'�3 UNIT IV <br /> NO: " <br /> OWNER FILC:COMPLETETHEFOLLOW/NG PROPERTY OWNER/NFORMATIOCHEcK1r OWNER CURRENnYONFiLewTHEHD El <br /> PROPERTY OWNER NAME (,'/) �- 2,3,-- 7 <br /> First Ml Last PHONE NUMBER Z-1/- <br /> BUSINESS NAMEE-"L AooREas <br /> GZ-,� 1'fL�P�2 c1�� ��--��-- <br /> Owner Horne Address <br /> City STATE ZIP <br /> Owner Mailing Address <br /> Melling Address City State Zip <br /> --IG TZS s-J L-1-9 <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION—ENVIRONMENTAL AssEAEMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP_ <br /> FACILITY I D# INV# ACCOUNTID PRWR0# ASSIGNEDEMPLOYEE LEAD AGENCY.EHD RWQCB_DTSC_EPA_ <br /> R�& x`76 03 OS 3 (- 4 <br /> FACILITYFILE COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE/NFORMAT/ON' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business!LOCATION but a NEW TYPE Of regulated Business? YES ❑ No <br /> BusINESSIFACILIT/ISITE NAME C <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> CITY STATE ZIP <br /> �j�-��,•-Tc�--.� C,ot �1-5 z Z <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYi KEY2 <br /> Mailing Address NDIFFERENTItow FactlItyAddra" Attention:orCare Of(got/ona/) <br /> Mailing Address City STATE zip <br /> SIC CODE <br /> APN# COMMENT: <br /> J���T »9-2� <br /> THIRD PARTY QILLINO INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME AttenUon:orCare Of(opbb tel) <br /> Mailing AddressPHONE <br /> mp,—, -Z— <br /> Cm STATE LP <br /> ACCOUNTAIDDRESS for fees and charges OWNER FACILITY/BUSINESS HIRD PARTY BILLING <br /> I31LI,INr;A.Np Com?LIAYCE ACK.yON'LEDCstT�,T: f,the undersigned Applicant,certify that I am the Owner,Operator,or AuthoHZed Agent of this Business,and I■cknoeledge that ail PERAIIT FELT, <br /> Pt.mLOPS,ENroRcFsrEvT CHIRGFS and/or 11ouxtr Cli4xufs associated W ith this operation will be billed to me at the address identified above as the ACCOI^TADDRLSS for this site. I also certify that <br /> all Information provided on this application h ave and correct;and that all regulated activities hill be performed in accordance with all applicable S.av JoAQCIN Cot1TY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERwL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,1 hereby authorize the ivivase of <br /> anv and all results and environmentai ussesnment Information to SAN JOAQUIN COUNTY F\lTRO\"YTEhTAL HEALTH DEPARTYfEN r as soon as It is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) d(LT N w t�s� , [»'�y R q SIGNATURE <br /> TITLETAx ID# l <br /> By AcoountiOffice Proceasi Completed B Dat. <br /> SITE MITIGATIONT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE:$" AMOUN ,�l I C / /1! C;T <br /> OiL*f pr5'7�L <br />