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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM SITE MITIGATION&LOP 6HADEDAREAQfp3.EH2VQLQNLY OWNERIDN CASE 111 UNIT IV OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF O{tN£A Is CURRENT[r ON FILE MTH EHD PROPERs TY OWNER NAME -C,-ft V-.- F'� (,AGC , d ) "/11((—,6z-,y,4FIRST Arl a� LA:: fit- T{„-k PHONE NUMBER DUSINESB NAME l a� Die S-b,,gym, Ple"thS/AK E•MAILAODRESS OWNER HOME AODRE68 4l , be>< ®� ZUl W. W/IAIt CITY SfiD71--i BGt4 LP 9 -2- OWNER b MAIUNa AnFIESe S Ats'tiL.f GY.D 4410u MAIuNoADDREBSCITY STATE 21P 'Set.,rn_l &4tL�- ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPOIISiBLE PARTY ❑OTHER SITE MITIGATION_. _ ENVIRONMENTAL ASSESSMENT._._VOLUNTARY CLEANUP_WATER QUALITY—.HW PIPELINE INVESTIGATION LOP FACILITY ID q INvN AccouNr ID PR OI RO p ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB—DTBC—EPA— ' FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO 8' IS THIS AN EXISTING PROJECT LOCATION,DUT A NEW SCOPE OF WORK? YES B NO ❑ DV9L•IEes1FACILRY1SREfPROJECT NAME SITE ADDRESS I PROJECT LOCATION 10he will d lrf— sfe, Are SUITE# BUSINESS PHONE CITY `*CI'tm-, G�STATE LP '7 6 BOARD OF SUPERVISOR DISTRICT b3 jLoCATIONCODE KEY1 :1(-7217 MAILING ADDREBB,IF DIFFERENT FRDM FACILITY ADDRESS ATTENTION:OR CARE OF(CPTIONAL) 2z O/ IV, V too (3a-, 24941 MAILtNOADDREB9 CRY Stock Cot- LP q:52-D / SICCODE APNN d 7 COMMENT: 1G2� Ot30—� THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY 13 DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME ajitu ATTENTION:ORCARE OF(OPTr4VAL) MAILING ADDRESS//SS N• FLI”t Pnone `1�i1.£ct .S��cff 2Ul `l DD (vOG `5917 Cm �J�Se BTAATE ZIP ACCOUNTADDREBS TO SEND FEES AND CHARGES: OWNER[:) FACILITYIBLISINESS❑ !� THIRD PARTY BILLIIIG❑ DILI,IN'O AND CII11fl.lANfF Af HYOnT.Fnf,MFN7; 1,tilt undenlynrd Applicant,rrrtlry that I am tiro Garner,Olnvamr,.hnhnrl:rJ rlgcnl,or RespunslEle faro-anal 1 ncknnnledge that all Prkwrr6E.T, PI.,%�ILrIGT,I.'NI-IR!'r,IIE.YFrli,lArual'nndlar IIULFLr('IL1Fr:r.T a...rialed nigh Ihh project trill he l,wed 1.me n1 Idle nddrtss Idcnlinnl At—,as the ACLTIL'.\TrlfrMl'.[e far Ihlt site. I alto rerliry,Iltat nil InformMion provided on this nppl'irahnn h true anal er.rrect;and that all regulated ariltilles VIII he perf—rd In arCafJan re ltlns all applirallle SAN JOAQUI.N GOUTY GRDI.VANCECDIIFS➢ndlar St,tNnARns And STATE And/or FEDERAL Lori and IITCLIATIO\i.As tlm undersigned Onnsv,Uperutnr,drrl(enr,':n1.�Rnn,or Respauslble rurry for tilt prnjrrt located al—e undtr faclUtyl.ite a:IJrttb I herthy A➢thorize the release of Any and ail resulit,repares,and other tn%lrenmttiml mintnitnt infnnnatino to SAY JOAIJLIN COLTIT\'EnTn 1St1F.NTAt.I11AI.TTI DEPARTMENT as soon as it le a�Aliohk And At the some lime It I1 pr%Ided in me or my repreten:ntive. APPLICANT NAME(PLEASE PRINT:/ s �j SIOHAIIHnE / f � ■ TITLE —� 1 TAX ID N 12 AP►ROVlO BY DATE ACCDUNTW G OFFICE PROCESSIN U CCN PLETID BY DATE SITE MI ATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT N CHECKS! RECEIVED BY WORK PIAN PE FEE:; l7S !?!� 3-2U�/LI C r+Ea K 4 75 g 3G �VG1#v�2 )