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• c6RAn IT <br /> San Joaquin County Environmental Health Department <br /> 7T GREEN FORM <br /> DATE Fa y 12 MASTER FILE RECORD INFORMATION MFR SITE MITIGATION&LOP <br /> SHACED A9968OR END USE OHL OWNER ID# O(Japa:,43 CASE# Seco Cc` 868 y UNIT IV <br /> OWNER FILE:COMPLETE THE FOLLOWING PROPERTY OWN ER INFORMA TION: cw[cKtr ow(NE�RjcuawevrzrONF2e wirN EHDEJ <br /> PROPERTYOWWNER NAME ('ti U r' D <br /> First MI Last PHONE NUMBER <br /> ///��� yE 11-ADORE$9 <br /> BUSNESS NAME da 1Z <br /> C-ll � l _QI Ivy v/GGLLQQ� G1 <br /> Owner Home Address * f /F��/`J�[/`� Fr��J <br /> city LOW <br /> ✓"I STATE ZIP�✓/� <br /> Owner Meiling Addressi- <br /> state Zip <br /> Mailing Address City rpm <br /> CORFORNTION❑ INONIDUAL❑ PARTNERSHIp❑ FEDAGENGs❑ OTHER p <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENTC VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILRY ID# 'II3V# ACCOUNT ID R RO# A.IC E EMPLOYEE LEADAGENCY:EHD_RWGCB_,OTSD_EPA . <br /> I2 L$ 3 54L63-10S,,71 , <br /> FACILITY FILE COMPLETE THEFOLLOW/NG BUSINESS I FACILITY I SITE INFORMArlom, <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> 191 <br /> Is this an EXISTING Business LOCATION butte NEONTYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESSIFACILTTYISRE NAME <br /> SITEADORESS SUITE# BUSINEWPHONE <br /> STATE ZIP <br /> Cm <br /> / ©�� T/\T Z1•� <br /> BOARDOFSUPPEERRVISORDISTWCT LOCATION CODE lie, KEr2 V <br /> Mailln Addrase if D1 FER NThomF iWAddresa Attention:OrCare Of(00011,70 R <br /> IJ <br /> 0717L— <br /> Mailing Address City / STA ZIP CN1 <br /> G <br /> SICCODE 11 APN#.. GONNENT: <br /> THIRD PARTY 13ILLING INFO: Complete if Billing Party is different from Property Owner or-Facility Operator%dent%lied aDOVe. <br /> BUSINESS NAME Attention:orCare Of(Optional) �r <br /> r VeU1k. <br /> Melling Address PHONE /—n�� -N <br /> W,,,,_,, <br /> I� A <br /> STATE C — D'P'I 0/115873[ 587 <br /> Cm <br /> G �IM6 <br /> Faa ACCRIPMADORESHfor fees and charges OWNER FACILITYIBUSINESS THINE)PARTY BILLING <br /> RILI.IVG.IND COMPLIANCE ACKNOwLEDGa1FNT: I,the undersigned Applicanq Corot)That[am the Owner.Operaftm or Authorhed AgmN of this Business,and I acknowledge that ail PCNJI/T PEES, <br /> PE\1LTiLI,E:\(OH(EIIEbT CILaRGEf and/or I(DENLI 014RGFs associated with this operation will be billed tome at the address i ividif ed above as the A('CO[4TADDRFSS for this silo. I olso certifIthat <br /> all information provided on this application is true and correct;and(hat all regulated activities will be performed in accordance with All applicable SAN JOAQUIN CI1hereby,yOrdinan authorie Codesce and or <br /> Standards and STATE and/or FEDERAL taws and Regulations. As the undersigned owner,operator,or agent of the propene Incased al the above facility/site address, <br /> am,and all results and em,immucittal assessment information to SAN JOAQUIN COUNTY ENN TRONATENTAI.IIEALTH DEP.ARThd ENT as so o it is availahle agd at the same time it is <br /> providM come or Or,represaa(alive. <br /> APPLICANT NAME(PLEASE PRINT) U`lid '1 V41r 7 SIGNATURE S �/u TAx ID#O6 — l 6 S � l <br /> TITLE �0 r r <br /> Approved By Date A cOOuneng Omne Prpcesaing C«npleted By ate (c I <br /> SREMnnoAT1ON AMOUNTPAID DATE OF PAYMENT PAYMENTTYPE RECEIPT It CHECK# RECEIVED BY WOR PL NPE <br /> FEE:: V <br />