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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> DATE , MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER IDS ��Doaz?SG CARE � UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNERI RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENR r ONPRE WITH EHDEl <br /> PROPERTY OWNER NAME �O�y,Ar I Ile \A. 1 \�� (114 0 4� <br /> FIRST MI I"YJf' �C QST 1PHOONENUMBER <br /> BUSINESS NAME EHIAILADDREW` <br /> OWNER HOME ADDRESS <br /> C01,e., <br /> Cm <br /> ST 'fl:,s zP q SI <br /> OWNERMAluNGAODRESB C' � <br /> i"L� <br /> MAILING ADORE99 Cm J a v GVF,_, L-N v - 3TC �L LP 5-2-01 <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP 9p`{LOVERNMENTAGENCY El RESPONSIBLE�PAM ❑OTHER <br /> 317E MITIGATION_ENVIRONMENTAL ASSESSMENT Y,VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FAcam lDt INv{ AccouxT lO PR ROS ABSNJNEOEMPLDYEE LEADAGENDY:EHD�RWQCB_DTRC_EPA_ <br /> fkDV 1�3 AQoo.�9 X0,05 G99 �OI�NNy <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YSMW;k NO ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No ❑ <br /> BUBWESSIFA 6iSGFJPRWECT NAME <br /> 9'S P. (JT <br /> SITE ADDRESS I PlbI LOCATION I A / l ! SUfTEV BUSINESSPHONE <br /> Cm ATE zip <br /> BOMDOF SUPEXVIbOfe DIBTRmr I LOCATION CODE / KEY/ KEY2 <br /> MAItfNO ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> MOUND ADDRESS Cm STATE LP <br /> SICCODE APNt f � 2_Ozv— U 1 CDMMEN,%.. <br /> THIRD PARTY BILLING INFO'COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RE8PONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME /� f1 Tc �{//yyyy IS <br /> a ATTENTION:ORCARE OF (OPT/ONAL)�� <br /> MAILINGADORESS 00, �r -l� J..-�'L�w PHONE p•t ® f F^r1 4 <br /> Cm ( V.A, Ll t 1 t �.� HrP'`/"tom) TE r4/{` {.47-P] 6ef cf VrD(��TJ <br /> Itf <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING❑ <br /> BILLING AND COMPLLWCE ACKNOWLEDGMBNT] I,the Undersigned Applicant,cerdfy that l am the Owner,Opernsor,Authorfud AgenAPrRuponsibl,Parry and l acknowledge that all PERAfrTFEM, <br /> PENALOhS,ENh'oxcureAT GLuers anNor Hoaxer Cluxcxs associated wiN this project will be billed tome at the address identified above as the AceovA Alwx for this site. 1 also certify that W <br /> information provided on this application is true vad correct{and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDmANcE Conti and/or <br /> Sin DA and SrAIE adpar Fr ERAS,Lam and REGULTIIoNs. As the undersigned Owner,Operator,AalhorieedAgenA or ResponslAleParty for the project located above under facility/site address,I <br /> hereby Inst arim the release of any and W resWb,reports,and other c vironmenDd assessment informadoa to SAN JOAQUIN COUNIY ENVIRON IAL HEAL'1'N DEPARTMENTAssoon vs it h available <br /> and at the some dose It Is provided to me or ;rI;ucsentadve. , �j <br /> APPUCANTNAME(PLEASEPRINT) (�,^,VA^� f �r((�1 T'/ SIGNATURE �1 <br /> TITLE ?rQ YVAH T"IDS --- V�•A� ? 1 �. <br /> APPROVED BY DATE ACOOUMDNG OFFICE PROCPJISMKa COMPLETED BY DATE 77,3 <br /> a"MITIGATION I AMOUNTPAm DATE OF PAYMENT PAYMENTTYPE RECEIPTS CHECKS RECEIVED BY -PE <br /> FEE:/ 37J 3�S 3-e�r- "�,, ek&d I 14/9 120QVTCIZ "�° " <br />