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_ E <br /> �1 I <br /> San Joaquin County Environmental Health Department <br /> DATEI / MASTER FILE RECORD INFORMATION"MFR`n GREEN FORM ' <br /> SITE MITIGATION&LOP <br /> BxAp! AR BEOREHDUSECKY OWNERID# UNIT IV # <br /> OWNER FILE ICoWLETLYTyjEPoLcowlNGPROPERTY OWNER tNFORMATTONr CRErawOWNER CUURRRE-NNITTOR'R11rVATITENO <br /> PROPERTYOWNERNAME : I e,,rre v I e l7 <br /> V <br />. Flat - Afl L85I PHONENUMSER <br /> BU&NEw NAME E ILADDRESS <br /> ovner Hame Address ! G/ ^ / <br /> CRY (/a L (•S T STATE i+ zip <br /> Owner Mailing Address <br /> 67t 1,-7 <br /> Mailing Address City L7 - State . Zip i <br /> CORPORATION❑ . INDMDUALE PAivRGAsNIP❑ FEOAOENCY❑ OMER❑ k <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT._VOLUNTARY CLKMUP_WATER QUALITY_HW PIPELINE INVESTIGATION—LOP _I <br /> FACILirfloil INV# MCOUNTID •eveajio— ASSIONEO PLOYEE LEAo AaENOY:EHq�RWOOB DT8C_EPA_' <br /> 379 <br /> FACILITYPILE CbMPL'ETIFTHEFOELOWINT:FBUSINESS/FACILITY/SITE INFORMIA UNr <br /> Is this R NEW Business LOCATION notpreviously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YEE ❑ No 0' <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No 0-- <br /> SWINESS/FACILITY/SITS NAME <br /> SOEADOnE89 �r7 <br /> -� �C ` Y SURE# BURINESSPNONE h <br /> CITY / G .. STATE,'4ZIP <br /> l - C v C/, <br /> BOARDOFSUPEftMwO DIaTRIGT -LOCATIONOODE Kul KEY2 i <br /> Mailing Address fFDIFFERENT'tFom Fh I%rAddtesar Attention:orOare OF(bpgbtlal7 � <br /> Msllrrlg Aaare88ORy �f�C �pl r teA - STAI`t-- Zip 7_7 <br /> BIOQOOE /::.: .APN# - COMMENT: ` <br /> THIRD PARTY BILLING INFOI Complete if Billing Party is different from Property Owner or Facility Operator Identified above. j <br /> SUSINEw NAME Attentlom orOare Of(bpabna{J <br /> AM- vc:�,�F-� <br /> Mailing Address PHONE :I <br /> Cm A / 4:2 t' N/(C l - STATE ZIPC�!% <br /> AccolifirA 11lie4S for fees and charges OWNER FACIUTY/BUSINESS THIRD PARTY BILLING <br /> BILLIYGARDCOMPLIANCEAcI o%O T.EDGNCAT: I.the undetaigned Applicant,"ttilp that Ian,the Onner,Opemror,orAutharittdAgent of this Business,Rod I aclmmrledge that all P£RvrFFEes', <br /> Pt uu,,E,YFORCFUEATCAAROFSnad/Drliovmi'CmAwanss iatednith this operationwillbe billed to meet the Rddret identified above as the ACTOUMADORFSS forlhlsslle IalmeerNfythit <br /> .11 Information prodded a.thisappileadan is true and correct;and that all regulated nethida will be performed in accordance uilh all applicable SAN Jog Coln Ordin:ace Codes and/or <br /> Siandardsand STAT AndforhTDERALLaWsand ReEWations.As the undersigned earner,operator,or agent ofthe property localedat the Ahos<fnciliry'hite ad rss,Ih eby salhodze the releseof <br /> any end all retulb end cmimnmenlal assessment informafiou to SAN JOAQUIN COUNW ENVIRONAJENTALREALI-R DEPARTAIENT,ssoo`n os is s.n' le and at the same time it is 1 <br /> prodded to me or myreprtseabdTe. <br /> APPLICANT NAME(PLeaaE PRINT) �j . S� �w(� SIGNATURE <br /> TITLE - /' TAXID# <br /> A roveds Data Acconnan OMce Proceulrq Complaled By Dote �D /Z <br /> SITE MITiIAOf1TION AMI�OUNTy/PAIO�p DAT7Of PAYMENT - PAYMENTTY RECEIPT# CHECK# RECEIVED BY WORK PLAN PE I <br /> ( 1 <br /> iaK. I 1 <br /> 1 <br /> ` 1 <br />