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San Joaquin County Environmental Health De artment GREENFORM <br /> DATES y f 2 MASTER FILE RECORD INFORMATION MF SITE MITIGATION&LOP <br /> UNIT IV <br /> =CA11 <br /> ::: <br /> A EHO use ONLY OWNER ID% <br /> CHECNLF OWNER CURRENnYONFILEWLrN END <br /> OWNER FILE:COMPLETE THEFOLLOWWG PROPERTYOWNERINFORMATION: cam O <br /> Praoperre OWNER NA MEI Rif Last PHONENUMBER <br /> First Mi <br /> n E-MAILAD <br /> BusiNE98NAM �� <br /> E C/� / �.y,{'I <br /> Owner Home Address / )pG�v�`�I�N <br /> Lod����pp S� ZIP y5� <br /> cityLid/- <br /> owner Melling Address <br /> State ZIP <br /> Melling Address City <br /> INDIVIDUAL El PARrNEasHIP❑ <br /> FED AGENCY 13 OTHER <br /> CORPORATION F1 <br /> EFIyIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_NW PIPELINE INVESTIGATION_LOP <br /> SITE MITIGATION_ RWQCB_DTSC_EPA— <br /> FA01LrIY IDN INV# AOCOUNT ID PRNI RON AMMEDEMPLOYEE LEAD AGENCY:EI•W__ <br /> FACILITYFILE COMPLETE THE FOLLOW/NGBLISINESSIFACILITY/SITE—/#FORMATION.' <br /> YES ❑ No <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES L] No <br /> Is this an EMSTING Business LOCATION but at NEW TYPE of regulated Business? <br /> BUS W E991FACjErrrSrrE NAME <br /> ,f,ISUaEN B..NEM PHONE <br /> SITE ADOR96 E /I/1 <br /> �� STA ZIP <br /> CM Lo ct A <br /> BDARDOP SUPERN80RD18rRlOT. LocATIONCoce. <br /> KEY1. KEY2. <br /> Attention:orcare of(000ns0 <br /> Melll Address iYOl FER NThomF FlifyAddress <br /> 5 e / r' L aTA AP C/ E <br /> Mailing Address City Ii,� <br /> 91C CODE <br /> APN A COMMENT: <br /> THIRD PARTY BILLING I14111 <br /> ,0- COYri/Jlete d Billing Party is different from Property )WDerr oerFaciolty OperatorCare aidentified above.Aftr <br /> BDeWE99 NAME V�I• r <br /> PHONE /)��f' <br /> Meiling Address I� ✓✓Illi 11 <br /> Cm f STATE 2F 0115F3 <br /> LAOQOLaTADoBEMW for fees and chargee <br /> OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Bu,wrvG AND CQ,eewarvce ACENONLEp6aIe;NT: I,the mdersigned Appli,A., certify that I am the Ouvrer,Operamq or durhari,-cd Agent o[This Business.and[acknowledge Tindall Paxw/r Fees, <br /> the mich-Ess <br /> fied <br /> ve as the <br /> that <br /> PEN4LUES,ENFORCEMENT arIRGEA id$application ar ,,,aE,r CH and GES associated <br /> al with <br /> this <br /> sa Reed operation <br /> actwill be biill 1IM performed in accordance ewil fill applicable SAN IJOAQUIIN COUNTN Ordinance CadNTADDREA5 for this site. I Alan e r0nd/or <br /> all information provided o <br /> Standards and STATE ed on <br /> his li Laws end Regulations.correct; the undersigned owner,operator,or agent of the properly located at she above facility/sive address.I hereby authnrae eM1e release o <br /> aent information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as sno it is available aI at the same time it is <br /> any and all results ad environmental assessm <br /> provided m me or my representative. - <br /> /,,� Q SIGNATURE <br /> DRE <br /> NAME <br /> APPLICANT (PLEASE PRINT) [ I VL V�\ <br /> TITLE \ '\ r 4b L'.. �! - <br /> oete <br /> AFPrwed ECEIPT# CNECNN RECEIVED BY W-..PIAN PE <br /> BY DBb AccaurlUnOOMce Pro RcomBComPlatetl BY <br /> SITE ^""T'^N AMOUNTPAIO DATE OF PAYMENT Pr <br /> ----+� <br /> FEE: <br />