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0 • <br /> San Joaquin County Environmental Health Department <br /> DATE 3 31 I MASTER FILE RECORD INFORMATION ENMFR's GREENFORM <br /> SITE MITIGATION&LOP <br /> 1 DWNERIDN CAPE N UNIT IV <br /> OWNER FILE:COMPLETE nYFFOLLOW7NG PROPERTY OWNERINFORMATION.' CNEwfs OWNER CfRDe£.vrtroNrHE wrm EHDEl <br /> PROPEInvom so-w" $nevi vie,ke. (636) 2,9,4-7 11 <br /> First MI Lest pH NUBeaa <br /> BtNIHEM NAYS S11e\1 011 ?YDducts SAS HIAILADOREW <br /> Sin brevirl�ke@Sl�clll <br /> Owner Home Address <br /> 20 S. Avfvlv-e, <br /> CRT Caysav� Hca m908,1 D <br /> Owner MEIIing AddrDEe <br /> 510.Yn-r— <br /> Mailing <br /> Melling Address City atZip <br /> CORPORATKIN INDNIDVAL❑ PARTNERSHIP❑ FEDAGBIDY❑ oTHgn❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY IDN INv1 ACCOUNT ID PR N/RON d`DNED P �E .uADY oENOT'�HDIiP�gC eDT90�', as4EpA sem, <br /> v„ e ,4,.e„Tih. 1 "�*•so @s° �ys i� dFh2'''R*�i'ei <br /> ys %.:. <br /> FACILITY FILE COMPLETE THEFOLLOHWO BUSINESS/FACILITY/SITE INFOR9477om <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? TEs ❑ No [Y - <br /> Is this an EXISTING Business LOOAnON butt as NEW TVPPEE of regulated Business? YES ❑ No [ <br /> BWWEesIFACAmIarre NABS SV\e-l\ S (:>d<- TM "(2VYv11V10.1 <br /> SMADOHEW '3j 15 N0.v W v-e- sum <br /> Co )e47'1,- <br /> Pa1,- <br /> Cm CA W75L0 <br /> 1Ann <br /> e941 <br /> BDAnDOP SUPEIlweO11O0rRcr \-TTG LOCmpoll CODE KEH KM. <br /> MRDIng Address RO/FFEREMHovn Fedf/(yAtAyreve, Atte dlon:wCare Of lopegvell <br /> GC VV1� <br /> Mailing Address CRY STATE ZIP <br /> SIC CODE APNN <br /> THIRD PARTY BILLING INFO: Complete if Billing <br /> �Pa��rt``y is different from Property Owner orlEaollity Operator identified above. <br /> Bwwm NA Cov1 e 6t- n vt,;, j f,SSo c�a-+c S Atterdwn:orCars,Of TpPDODaII <br /> D <br /> Ma1IgA7W.W59o0 {lotus Si�ree-t Sup A <br /> 1 ,, CPS I o) ¢2p-3336 <br /> Cm v L L.E. <br /> l -A <br /> A41DDI/AP�OGRENB for fest and chargW OWNER FACWTYBusiNES5 THRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT, 1,the undersigned Applicant,certify Nat 1 am Ne Owen.,Operator,or APrhoriced Agenr of this Business,and I acknowledge that all PER F= <br /> PEN Xa,,ENFORCEMEATCHMGET and/or HOVRLYCHARG&associated with this operation will be billed to me at the address identified above as the ACCOVNTACDR:&y for this site. l allo certify that <br /> all information provided on this application is true and correel;and that all regulated ectivilin will be performed in accordance with a1I applicable SAN JoAQNN COtm ry 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 the above facility/site address,I hereby authorise the release of <br /> any and all results and envimnmmbl assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a soon es it is available and at Pov same time it is <br /> provided to we or my representative. <br /> APPLICANT NAME(REAM PRINT) S,i vy\ DyQyiyte-�� <br /> TITLE Sevt�\tTY �MD Y-C.YYY Mav\okgev- TAXIDO <br /> Apprised By Date Aso iii Ohba PrommOng Con lebd Duty <br /> 111MMM"TroN Awuw Raw DATE OF PAYBEHT PAYaENTTYPE R1 1 TO CHECK NRECBVED BY ✓ PiiiYl''� fix.'.. <br /> FEE'O 041�0 Fob a ��7 S <br /> u, <br />