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SAN J*IN COUNTY ENVIRONMENTAL HEALTH daRTMENT <br /> DATE 2 _'�4_ I'� MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> J SITE MITIGATION& LOP <br /> SHADED AREAS FOR EHO USE ONLY OWNER I0# CASE{ UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWWR IS CuR . <br /> wfih V ONFAE MTN END <br /> PROPERTY OWNER NAME N%r \u''16(1-0j OG �S <br /> FIRST MI UST PHONE NUMBER <br /> BUSINESS NAME s EMAIL ADDRESS <br /> OWNER HOME ADDRESS .� <br /> Cm ^^ �7 1 <br /> �l�"C LP-c[��1 <br /> OWNERMmuNo ADDRESS �30 'rS O x ZO k U 1 ta <br /> MAILING ADDRESS Cltt �" �¢ H STC 4V LP� �ZU I <br /> ❑CORPORATION G •/�' aTV❑INDIVIDUAL El PARTNERSHIP �(I{GOVERNMENT AGENCY ❑RESPONSIBLE PAM El OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT--VOLUNTARY CLEANUP WATER QUALITY HW PIPELINE INVESTIGATION LOP _ <br /> FACILm ID{ INV{ ACCOUNT ID PRORO{ I AssHFNEMEMPLOYEE LEAD AGENCY:EHD,.LL_RWQCB_DISC_EPA_ <br /> doylvvci <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YrXgEk; No ❑ <br /> IS THIS AN E%ISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No ❑ <br /> SUSINESS/FACIL fSRE/PROJECT NAME <br /> SITE ADDR`EESS/PROJECT LOCATION 5 � � / . / ty 1 �G ` SUITES BUSINESS PHONE <br /> Cm J 1 V C,to "r LI� l- (� RTATE LP <br /> BOARDOFSUPERVISORDISTRICT J LOCATION CODE / KEY1 KEY2"' <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILre ADDRESS l ATTENTION:ORCARE OF(OPRONAL) <br /> MAILING ADDRESS Cm STATE LP <br /> EIC COME APN{ COMMENT: <br /> 5 3-azo- � �- <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME /Y F� /V }� P� ATTENTION:ORCARE OF (OPOONAL)�� <br /> MAILING ADDRESS PHONECfp•I �2 4 <br /> Cm C �.f V 11ll CTL wZATE �.LP P446Jl0 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ �•s;• THIRD PARTY BIWNG❑ anal <br /> Buaarvc AND CDMeLLAncE Ae1wOWL[DemeN'a: 1,the undersigned Applicant,cerdfy that 1 am the Owner,Operatar,AutAonud Agen4 or Respansibk Parry and 1 acknowledge that WIFERNITFLes, <br /> FLNs Tes,ENFORcevhATCI Kees andlor HovI YOmR4'e5 msoriated with then project will be billed tome at the addreM Identified above ar the AE000NTADDaFST for this site. 1 also cerdfy that ail <br /> information provided on this application is Irue and corrtetp and that ail regulated activities will be performed in accordance with W appdcabk SAN JOAQUIN COUMIY ORDINANCE CODES an&" <br /> SivmAROS and SIAIE awdlor F[DEM Laws and RECUL,vluns. A the undersigned Owner,Operator,Auslwrlred Agen4 or Reeponoible Port'for the project located above under facility/site address,l <br /> hereby authwrit the rerleaae of any and aU rnulb,reports,and Other environmental aaseIemrm Information m SAN JOAQUYN COUNI V ENVIRON !'AL HF.ALI'H D[eAR'I'M[NI'of sown as it b available <br /> and at the same dme It n provided more"m/,/y)�rep�rnenuative. I{ 1, <br /> APPLICANT NAME IPLEASE PRINT] (,mss l V, ,,L� I V Q SIGNATURE <br /> TILE frQ e�'.�c Y` AvN•Nt QTASIOB 5 �� �3L( <br /> APPROVED BY DATE AcD WINGOFTM.EPRm1F8aWOCOMPLETEDBY DATE <br /> SITE MiTm AnON AMOUNTPAm DATE OF PAYMENT PAYMEITITYPE RECEIPT{ CHECK{ p RECEIVED BY WORMLIPLAN PE <br /> FEE:i 375 �� 3"Z�I- l '/ Cl-(6! 11 U /4 / �Octa, <br />