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San Joaquin County Environmental Health Department <br /> DATE _ Z , ZL <br /> ASTER FILE RECORD INFORMATION MFR GREENFORM <br /> SITE MITIGATION& LOP <br /> fti& ¢AArw[foREHuu[EpJLL1f OWN IItN" �O 1 � C'a[/ v� O- f UNIT IV <br /> OWNER FILE:CoiImLETE rHeFOLLowwo PROPERTY OWNER 1NFORmwiTxxv.' ONedwir OWNER CUR*eVTLYON Fite W/M END <br /> PROPeRTYOWNrnNAME f f�j <br /> " First4- <br /> M! Last PHONE NINstER J <br /> BuswcasNAr[ y���) , l✓�7 � / � 1 �i EauiLAoDR[ta <br /> Owner Home Address <br /> caw <br /> °'ty �V- vi ru sT�[ ,� 1Z-(� 2U, <br /> Owner 114"Yg Address <br /> Moiling Address City SfstaZIP <br /> CORFOAAT-14� Ie1dNDUAL❑ PARTN[R[HM FEDAGeMY❑ 0T/t[A1 <br /> SM WTtaATWH EtmoosaMaNTAL Afaafamoff_VoLulmilty CLaANu►_WATm QuAurr_NW Pweura imusTmAT10N LAP <br /> FACILITfIDN IN" Accoua1T10A AMMEDEMPLOYEC LIMAoeNDY:EHD_—RWQCB_DTBC`EPA <br /> _ <br /> I2-93`1 :ZI 1�k2, 105�1 L" J <br /> FACILITY FILE COAiPLEIFF 7NEFOLLowiNO BUSINESS I FACILITY if SITE&FOR,M 4770N. <br /> Is this a NEw Buaiftess LoCAnoN not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes (71 No ❑ <br /> Is this an ExisTudo Business LOCATION but a NEw TYPE of regulated Business? Y[a ❑ No ❑ <br /> BusiNets/FAoRfTY/SffE NAats mOO I'l,r <br /> SITEADDREte 1 56)N 1� J� SUITE Butuat"PHOW <br /> c- /1� �j� Ca r y7 o rjL STATE Zw <br /> L <br /> BOARD OF suFERVIsoR DI[TRICT O L.oaanoN Coat 'T�} KEY1 K[Y2 <br /> MelWgAddrewM01FFEREAWA= feexAryAdabwe (( I AfMrrlfon:orCeevO►leP ++ ) <br /> Moues(Address City STATE Zn <br /> EIC Coo[ -7 ? APN II CaawcNT <br /> THiggo PARTY BILLING INFO! Complete ff Billing Party is difYorent from Property Owner orFacifity Operator idenlfied above. <br /> BOas, aa�iArr AHenlion:or Care Of/opWrael) <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> A00w4*q_4ggVAj for flit and charges OWNER FACtuTY/Buswess THIRD PARTY BILLING <br /> flILl.tNC AHD CDAtrt.aAN['[ACKNOWL6Df.'aIEM: 1,the uatlersigned Applknt,certify that Ism the Omar,tlptrater,or AmMarizrAAgenr of 1hM Rusinese,and I acknowledge that OR PEAAIM FEES, <br /> PEAK I TIES.LvFOACLAiE,vr rmARCeT arwLor Houat,r Q/.UOES associated with this olwal ion will be billed to me at the address identdfmd above as the AcrouAT ADDaerr for Ibis site. I also eertffv that <br /> all itrrormadoa provided Ott this appUeatfon I.true and correct{nad that AI regulated acdvliks At be performed In accordance wNh all sppUcable SAN JOAQUIN COUNTY Ordinaacc Cadn.'livor <br /> Standards sad STATE andlor FEDmki,Lana and Itegsiatiuns. As the undersigaed Owner,operetor,or agent of the proptrty locAted at the aboveIlitylsile address,1 hereby autharfre the release of <br /> any and all results and environaemnl assessment information to SAN JOAQUI O"rrrV ENVIRONMENTAL IIEAI.TH DEPARTMF o suun ss N b alb a and at the samr lime It Is <br /> provided to nae or my represenUtive. _ <br /> APPLICANT NAME(PLEME PRINT) L &ONATII [�— <br /> TITLE m� TAxID / - <br /> ApproviadayDab A000unUn OfRw►rtwaaa n C Nbd Data <br /> 7 <br /> EITEMITIOATION I ArODNTPAID DATEOPPAYMENT PAyhUNYTYF[ R[O[IK0 CH[OKA RE—MVIDBY WOaat PLAN PE <br /> FEE:3 <br />