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San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION"MFR" oREENFORM <br /> SITE MITIGATION& LOP <br /> SHADED AREAS FOR END USE ONLY OWNER IDM I 3 -2-f CASEM S"D I.3S*23 UNIT IV <br /> OWNER FILE:COMPLETETHEFOLLowwo PROPERTY OWNER INFORMAT/ON: CHECKIF OWNER CuRRENnYONFLLEW1rH EHD E] <br /> PROPERTY OWNER NAME <br /> Fiat Mt Last PHONENUMBER �Et7 ,. 14-7— 1002, <br /> BUSINESS NAME t EIMIL ADDRESS <br /> l�� lON •J S�Li �–1 <br /> Owner Horne Address <br /> �(0 21•- (� S u �. �l�itu S b R . <br /> I <br /> Clht /� 87ATE ZIP <br /> V LS'Th q ZOS I <br /> Owner Mailing Address ,f <br /> As <br /> Mailing Address City State Zip <br /> CORPORATIO INDIVIDUAL❑ PARTNERSHIP❑ f EO AGENCY❑ OTHER❑ <br /> Srm MIT1mrohi_ENVIRONMENTAL AssEssMENTA_VOLUNTARY CLEANUP—WATER QUALITY_HW PIPELINE INVEST10AT1ON_LOP_ ! <br /> FACILITYIDM INV# AccouteTlD �PRqROM AssIONED MPLOYEE LEADAOEHCY:EHD RWQCB_DTSC_EPAIto�z 28 qg9 }{�lizt9 <br /> FACILITY FILE COMPLETETNEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMAT/oow <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 /> 8USINEss1FACIUTYISITE NAME <br /> SITEADDREss `` SUITE# SUSINESSPHONE <br /> l Z_62_ tj LAfto 4D o� 7_0 rt. -- <br /> CRY �� STATE ZIP <br /> CN <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 L�[KEY2 NVC�J <br /> Mailing Address ND/FFERENrfrornFaellNyAddress Attention:orCere Of(opb!6,wo <br /> MaMng Address City STATE ZIP <br /> SICCODE A IN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFacility Operator identified above. <br /> BUSINESS NAMER Attention:orcere Of(OPLAO sl) <br /> V L <br /> Mailing Address s PHONE <br /> 2. O'Z Cl I,L i _ 06 0a <br /> CITY STATE ZIP <br /> a q.S <br /> ACC2uMTAIDa n for fees and charges OWNER FACILITY/BUSINESS THI D PARTY BILLING <br /> BILLING AND COMPLIANCE ACK.NOWLF.DGMEAT: 1,the undersigned Applicant,certify that I as the Onrter,Operator,or AttthorkcdAge'nt of this Dusiness,and I acknonlget at all PERUIT FEES, <br /> PE,L'eLTIFS,E,YFURCEttEATCIIARGFSsnd/or//OULU.T CU,eRGF.Ssssociated ttith This operation mils be billed to use at the address identified above as the ACfOUATAADRE55 for This site. I also certify glint I <br /> sill information prosided on this application is true and correct;and that nil regulated actitities teal be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards anti STATE and/or FEDERAL Lass and Regulations. As the undersigned owner,operator,or agent of the property located at the above facilitylsite nddr sqqI hereby authorize the release of <br /> any and all results and emiroumiental assessment information to SAN JOAQUIN COUNTY ENVIRONNIENTAL HEALTH DE' tTAIENT as soon ns it' arditable and al the same time it is <br /> prosidcd to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) LLa4'_ �� SIONATURE <br /> TITLE II�o� ecT TAX I D# <br /> tsG��0 <br /> 3 tfr`t <br /> h <br /> Approved By Data Aocounling olflee Processing Completed By Date Z 1 <br /> efTEMITIGATION AMOUNT PAID DATEOFPA MENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> i <br /> FEE: <br /> Sr�7� 3�5 9,9 e+��� I ��d 2q�o <br />