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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATEMASTER FILE RECORD INFORMATION EE MFR" GREEN FORM <br /> 3zs- I<I <br /> C� $ITE MITIGATION&LSP <br /> EtMOfYeaEAE FOp No_La_ kY ONNEAIDR 01000/9 .TF-W(.9:L9Y UNIT IV <br /> .OWNER FILE:COMPLETE PROPERTY OWNERI RESPONSIBLE PARTY INFORMATION: CAECRIFO"mIACWYREmLYLWPILEAdWEHO� <br /> PROpERTYOmERNAYD SlG� bA(i( H (pf) q G-aEy6 <br /> Fmv MI LA. PJIt r PHDNENUMDER <br /> BUStNCSSNAME Die S-frcKfin Is �� E-YALLADDREei <br /> OwNeR HDYeAoaREEE 2-"f W. Wyk �� .�Wfi PD, Zell: <br /> CRYS17 C BTAT. LP <br /> CSF 9 6 <br /> OWNER MAILINGADDRess <br /> MuuuoAmEEBCIre astiYH� STATE LP <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GCVEtummIrAGENCY ❑RESPONSOLEPARPY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY IDR INVN Aaaum 10 PRRIROR ASSIO14ED EMPLOYEE LEAD ACEBm:EHO_RWQCB_OT6C_EPA_ <br /> oXI RRwww I T>gD538161 <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION M PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? VES ❑ NO 9- <br /> ISTHIS ANEASTINGPROJECT LOCATION,BUTA NEW SCOPE OFWORK7 YES 0 No ❑ <br /> OUSRIESEIFADILRYISRE(PROJECT NAME ! / Dn_Sl�C Ll-en ymE. <br /> SREADORESSIPmonaTLocATON /004 N 'ldlrfe SU_ <br /> BYSWESPHONE <br /> CRY $fie/e-7r'T �STATE Zip garzo/ <br /> BOAnourauPERVIEORDIStRICT 3 La¢Ation CODE KEY? 1(EY2 <br /> MAILING ADDREBB,IF OIFrER[NT FRDM FACILBYADDBEei ATTENBDN:ORCARE OF(CPRRVAL) <br /> zaof hl. V &ud- po. Isak zao"I <br /> MAIWAf ADDRESDCm S—mek-t "I 01— LP95Z0 / <br /> 61C CODE APLLM I/ 2^ LI0 r)6 �17 COMM[NT; <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLINJGJPARTTTYIIS 13IFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BBBINEBB NAME �fA �IYdw ATTENTION:ATCARE OF(APROVAL) <br /> LLCC H p <br /> MAIUNOADOREDB/Irt N- Flh.at 5� �/ PHONE yob &0& ''/'717 <br /> CITY •SJ 1`/ r t rarE Zar <br /> J� re 9s,r z <br /> ACCOUtrrAOORESD TO SEND FEES AND CHARGED! OWNERO FACILITYIBUSINESSO THIRD PARTY BILLING(] <br /> BGuvr.Avn Cnuruavry ArTrmatrnr:N[m I,it,,omkntenrJ APpRnnl, ndry that l sq 41he0,. 11, np RerPava/hk Pop•and i nrkamskd,that all PERJUr FTET. <br /> Frmim6$GNAMCEIIEAT GrnAtiec nnJ/¢r llamLrLTUAr.Esn+nr alN nllh Ibk prphet will be blued to me nt the midrm ldmIIOMI akaro as[tic ih=i mTAnumirm for flits rur-I Plan"Wry Had nR <br /> InfRlmalko Prpvhted on @Ir nppllealloa k Ime ami mmll and Nml nil".1.1ed.11,111n xK1 be perfarmed In aeeardance ndib all applicable SAN JDAOLTN COUNTY 011114 NCE CODO and/or <br /> STANDARDS and STATE andkr FEDERAL U.and R[CLTATIDYi M the nnJmlEnfJ lh,vn,tll rraroa Amhod;NAie.R,ar Rerpanrlhfe M¢f¢r the pmjeel Ietl1eJ above uvdm fRelWyhlle WdreY,i <br /> h<rtby nvlh¢rk¢Ili¢nlna¢¢f nvy and 0i1 mulls.nearly ami albn fnrirnnmfnlnl nffmmml Infnrmallan 1¢SAYJGApLTN DULTrtY F.KYTIIDNARMAL TI[ACIII R[PAITTII[Mraf Avon of 11 k vailebk <br /> mJ el the same Ilme k b pravlJeJ to me or my npmmnlire. �//%J <br /> APPLpMRNAME(PUAEEPRINTP�,I� ern SIGNATURE '�'/• %SSI YA/ <br /> TRLE _, A-y Tax IB <br /> n <br /> AprpPJCOBY OAR FIfDVNnxa OFiICEPpaCfEAMOCOMPI£a[a BY all <br /> SITE N ATION AYOUNTPAm QATEWPAYYENT PAYMENTTYPE RECEIPT. CHECK. REOLRVED BY WORK PLAH PE <br /> FEE:mt 7' 375' 3-2�-/�I Cr+EeK 475934 eauxA7s2 2 v <br />