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San Joaquin County Environmental Health Department <br /> DATE .0-2-7 - t0 MASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> _____! SITE MITIGATION&LOP <br /> SHADEDAREM9FO uSiEONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:Co,NPLETBTHEFottowlNG PROPERTY OWNER INFORMATION, CHwx,F OWNER CuRRENrtroArfmEWIrH EHD <br /> PROPERTY OWNER NAME ) <br /> First M! Last PHONENUMBER 2.C>Ot— 1J,56—g']G t <br /> 22USWESS NAME E•MA&ADDRESS <br /> C'\C'� o>r mCa�f�EGt� TP�CiR\+ct�A®G� .Mcyst�cFZ• �•US <br /> Owner Home Address <br /> \ 00\ C EMNN2Z f c <br /> city STATE ZIP <br /> Mtatuzec(:) C Pk x'153 <br /> Owner Meiling Address <br /> Meiling Addrese City Slate ZIp het <br /> CORPORATION ElINDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER CK <br /> SITE MITIGATION_ENVIROPUMV rAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALFFY HW PIPELINE INYEMmATION_LOP <br /> FACILITYIO# INV# AecoLorlD PR#/RO# EAONED EMPLOYEE LEADAwNCY:EHD . [tWQCB_DTSC_EPA_ <br /> vuD 5Ql3 b� � . 5 VI y'L`-1 <br /> FACILITY FILE COMPLETE THE FOLLOWNG BUSINESS I FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES M No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES No ❑ <br /> BUSINESSMACILITYISITE NAME <br /> tr�'�`EGq �n.l4Tlmc,�c��. S�ra:�oT� <br /> SITEAooREq SUITE# BUStNESS PHONE <br /> cm STATE ZIP <br /> cc w' C C15 3� <br /> BOARD OF SUPERVISOR DiSTRtC7 LOCAnoNCODE Keri KEYL <br /> Malling Address KOBFFERENT fnvm FocNllyAddress Attention:orCare Of(opb;okrw1) <br /> Mailing Address City STATE ZIP <br /> mom, c�c� ON X5337 <br /> SIC CQOE APN# COMMENT: <br /> THIRO.PARTY BILLING INFO: Complete ff Billing Party is different from Property Owner orFacility Operator identified above. <br /> BUSINESS NAME Attention:orCtare Of(optYWW) <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> for fees and charges OWNER FACILITY113USINESS THIRD PARTY BILLING <br /> BILLING AN•D COATPLIANCE ACKNOWLEDGMENT; 1,the undersigned Applicant,certify that 1 am the thrrrer,Operator,ereluthori.edrig nt orthis Business,and I acknoN•Icrlge that all PEAN?rE@s, <br /> PENALTIES,CA'FURCEmENFCH.IRGES and/or HoaRr rCHARGES associated with this operation,will be billed to me at the address identified above ns the AccouVrfIDORE85'for this site. I also certify that <br /> all Information provided on this application is true and correct;and that all regulnted activities will be performed in accordance with ail applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Lass and Regulations.As the undersigned owner,operator,or agent of the properly located at the above facility/site address,I hereby authorise the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN•r as soon as it is available and at the same time it is <br /> provided to moor my representative. <br /> APPLICANT NAME(PLEASE PRINT) 5441 P[u 8f P E Ci R\,64;;�A SIGNATURE <br /> TITLE TAX iD# <br /> -��P,NS<e' cna�.rR(��s4Z C�� of MF3�•sz:'s✓�-*,fir �� 'Q\/tJV ��G l(i <br /> Approved By Data AccounW l')ffloe ProcoasIng Completed By \ Date r <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE ro <br /> FEE,Z, zj�eg rI�OZ IO Ll� <br />