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San Joaquin County Environmental Health"Repartment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> SITE MITIGATION& LOP <br /> SHADED AREAS FOR END USE NLS' OWNER ID# CASE If UNIT IV <br /> OWNER FILE:COMPLETEPROPERTYOWNER/RESPONSIBLE PARTY INFORMArtoN- CHECRIFOWNER CURREHTLYONFLLEH#THEHOL1 <br /> PROPERTY OWNER NAME Cl(/n 5rr �top <br /> <]Y ��� -Vto <br /> First MI Last PHONE NUMBER <br /> BU81NEs3 NAME <br /> E-MAILADDRESS <br /> �e�rot � UYxoca Tax �j-v�o,;�eCGtieuron.corn <br /> Owner Home Address <br /> city <br /> STATE LP <br /> Owner Meiling Address �O SO <br /> OX <br /> Melling Address City S <br /> LAN. Slaterx LP ?7'1S� <br /> CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY HW PIPELINE INVESTIGATION LOP <br /> FACILITYID# INV# ACCOUNTID PR#/RO# ASSIGNED EMPLOYEE LEADAOENOY:EHD_f�RWQCB_DT$C_EPA_ <br /> FACILITY FILE: COMPLETE BUSINESS/SITE/PROJECT INFORMArlo <br /> Is this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an EXISTING Project LOCATION but a NEW SCOPE OF WORK? YES ❑ No ❑ <br /> SUSINEBSIFACILRYISITEIPROJECT NAME <br /> SHE ADDRESS/PROJECT LOCATION SURE# BUSINESS PHONE <br /> CITY <br /> STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT d/ LOCATION CODE KEYT KEY2 <br /> Melling Address KD/FFERENTYrom Facility A ddmss Attention:orCare Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or-Responsible Party identified above. <br /> BUSINESS NAME yT� O= Attention:orCare Of (Optional) <br /> / Sv>-C <br /> Meiling AddressPHONE <br /> l61 C �ek5:de e GA-. S ;ke oo gItv.10U - 32�t <br /> CDv OSe'j-, 1� iz— Q STATE ZIP q S C- 0 <br /> Acacy&TAamw for fees and charges OWNER FACILrfY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKn'OWLEDG>tENT: 1,the undersigned ApplieanS certify that Isom the Owner,Operator,Authorized Agent,or Responsible Party and I acknowledge that all PE"ITFEts, <br /> P£A:4LPE.T.E1£ORCEAEAT L•HARGFS and/or HOORLY CHARGES associated with this project Will be billed tome at the address Identified above as the ACCWWADDRCSS for this site. I also certify that 911 <br /> information provided on this application is true and correct and that 96 regulated activities will be performed in accordance with all applicable S,LN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE andlor FEDERAL Laws and Regulations. As the undersigned Owner,Operator,Authorved Agent,or Responsible Party for the project located ainn a under faeility/site address,I <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it <br /> is available and W the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) , we- mk-4 l v SIGNATURE, � 1 a <br /> TITLE Tl/) I'C�rljl�- C� , lc�{ TAX ID# l-7/ <br /> YyiVJ`"'vl !lL/t D I 51- b3-]?), 224 <br /> Approved ay <br /> Data Aenounang Mee Processing Completed By Data <br /> $ITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br />