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San Jc uin County Environmental Health L artment <br /> DATE11 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> �-,^ I' SITE MITIGATION&LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER IDM CASE M 1U DO`p Lf'y-� UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOW/NG PROPERTY OWNER INFORMAT/OIINI., CHIECcx/F OWNER CURREHTLYOHFILEW/TH EHD <br /> PROPERTY OWNER NAME a <br /> KkLe..yG� Ar e t– r �v.,l�ii��yk <br /> V l RrSt MI Last `PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> Owner Home Address <br /> U �c•x 2 Zl <br /> City STATE ZIP <br /> (Vt I ll V"'II ea gy947 <br /> Owner Mailing Address <br /> Pb <br /> ziz <br /> Mailing Address City State Zip <br /> M II uall - C PtL,g4� <br /> CORPORATION❑ INDNIDUAL`P- PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION ENVIROMMENTAL ASSESSMENT_VOLUNTARY CLEANUP_IYATdk QUALITY_HW PIPELINE INVEwriGAT1oN_LOP_ <br /> FAatmID# INV# ACcouNTID PR ROMs <br /> v 2`7 <br /> FACILITY FILE COMPLETETHEFOLLOW/NG BUSINESS/FACILIT T i t5ITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No E' <br /> Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No E] <br /> BUSINESS/FACILITY/SITE NAME,— <br /> SITE ADDRESS SURE# BUSINESS PHONE <br /> CITY STATE ZIP <br /> '�— A q 522 <br /> BOARD OF SUPERVISOR DISTRICT v LOCATiON,CODE KEY1 KEY2 <br /> Mailing Address WD/FFERENTIlrvm Fac!/ityAddriess Attention:or Care Of(opflona/) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN M / n�D COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing/Party is different from Property Owner orFaciilty Operator identifiedabove. <br /> BUSINESS NAME I Attention:orCare Of(optional). <br /> �CtiVe o--51er <br /> Mailing Address PUONE <br /> z3; Vl2 r^cu 1Nc�� 5�; 1Sti (-7o-7 S--2 S - 10 I v <br /> CITY ..-� CATE R ^T S 40 7 <br /> AccauNTAaDmEw for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent or this Business,and I acknowledge that all PERAnT FEES, <br /> PENALT/ES,ENFORCEMENT CHARGES and/or f ouRLYCHARGES associated With this operation will be billed tome at the address Identified above as the ACCOUNTADDRESS for this site.12150 certify that all <br /> information provided on this application is true and correct;and that all regulated activities will be performed In accordance with all IN <br /> licabl .SAf+JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at th 2b facility/site 7ddl hereby authorize the release of <br /> any and 211 results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPArtim NT as�;ailable and at the same time it is <br /> provided to me or my representative. SIGNATURE <br /> CIX APPLICANT NAME(PLEASE PRINT) ,.I �:i6 CV Ye— <br /> # <br /> TITLE n� L TAx I D <br /> Approved By Data Accounting Office Processing Completed By Data <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORK PIOJy/W P <br /> FEE:$ <br />