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05/21/2012 07:36 FAX 6503651' B31C BOB 2002 <br /> San Joaquin County Environmental Health Department <br /> DATE r- I�- I - �, 1'Z. MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> I SITE MITIGATION&LSP <br /> Owner(D. cN�# n UNIT I V <br /> OMMER FILE tCOMPLETETNEmLLowNo PROPERTY OWNER INF0RK4710N: O+rsoKrr 6WNER OuxmwnromFmF*Tny END <br /> ismea Trom"MAW R b�jG y (F10)4 4 6 <br /> Fief Ml I Last PstpNE Nuareat <br /> nilswrasNAat. �� d o S M�KTl ,vh v-jL LL G ; L°fjroufwa mec�trnit <br /> owns Hort.Addws <br /> '9LAV r 1I <br /> 5'40 n ,�o <br /> city { zr <br /> OwrreT M04iNV Addrv" <br /> 5'a�ra,c <br /> tg&"Addrnaa Ofty Starts ZIP <br /> cataokA„oet❑ N1rNYttx>u❑ PARTNm{eetlt•G F!RDM nOYG 01NlxC�}� <br /> SM Mffl aaTM_SNM FaNMXrrALAp Pff ZVOLUNTAIIY CialtNUF_WATEt QUALM_KW PMELIMM IMvetn"TIOat_LOP <br /> PA8Itm 1D>f 1NV/ Appptsrrr lD PRNRON .;ANI 'LA L017[�. Lcan A0040rt EHD,L—jzw e—DT9C�EPA <br /> 777 <br /> FACILITY FILA CoMPLE7E ME'FouawrNd BUSINESS/FACILITY I SITE/NiORM4770N <br /> h thla a NEW BuWnais LOCATION nOtprWlunly repulwtad 4y the ENVUX*W9NTAL HttALTH DEPARTMENT? YDs C) NO C] <br /> Is this an Exa wa BuWrwxs LoeATION buts NmTYPE of reguWrted Business? Yap No ❑ <br /> at»INtaeIFAOkn'rdafrx titwe <br /> lianas ammo p"ONE <br /> anADoreeaa i�D S7- -V <br /> 1 <br /> n v� <br /> CATs zip <br /> BWuecvEsurerv�oKDtaTtaaT L—raa000e K. Km2 <br /> R AddraaL 1rDlFfE7�11fTAtY11 o AddHw Agwdion:orCan Of(OPNO a✓i <br /> %W IN p A&mm CRY STAL► <br /> sic coos AM* Coatarttr <br /> THIRD PARTY BILLING INFO: eeEeletai(l3illing Parly is d1fferentf1VMPruP0rty Owner orracnity Operator identified above, p <br /> Nmt/YIM MAara `T c.11 n o 10 �rec l-�+ UN v Y1 Atbwldion,cr Car.Of( /5-4 rA 17 S4-U�'f <br /> kl.alrw Aadr..a D f 0 o i h i r S ��r S l�1 -!c O O � 4Q¢ �/3 3 1�l <br /> cn,r STATE�� 7J► �171 <br /> 1 <br /> e ttneto"and ohwgm OWNER FACILITY/BUSINESS THmD PARTY BILLING <br /> 'BILLINC AND OMr1.aANt.E A0%N0WL[0Gr4eN1'= 1,the underslQaed Applbaoy certify that I am the O*ner,0.0eramr,or Axthorked Ment of this Bush"P,and t m4wowltdgt that ali PasxrY Fier, <br /> Pf•NAL17ES,EHrosCRhfit,N7CHAR(7fS ladlar Ko URLr cmAmGLS ataotiLt/tl with this operaklom*111 be billed tamest tae address identified above v the ACYOMIAQnRESS for this alt-. 1.Ina rtrlffy that <br /> ell laferma(lan provided an thic Application Is true and correct;mad that all regulated Seth ties will be ptrforn cd to accordant!with 10 applicable SAN JUAQWN COutm Ordfnaatt Coda andlor <br /> Standards and STATL■ndior FEDERAL LOWT pad Regulations.As flit undersigned owner,operator,or agent of the properly IOMCO at the aboYt fatiltty/eke■ddrtls.I hereby aatbo Axe de release of <br /> any and all mutts and onvironmrntel alNalateat ln[ormation to SAN JOAQUIN t:VUN'rY ENVIRONNTENTAL HEALTH RT''rTE tl loon u h Ir avall��d■h time 11 is <br /> provided to mt or my reproseotrim J'vlJr ra <br /> APPLICAMT NAME TWAEE PRINIT) /S G�0 J L} f. P Z16C SIOMATU H� <br /> TTT1.E ,�1 J ��, iY� ,�` a.� err��) <br /> TAX to* 33a3 08L <br /> Appraved 6+d f?Illna.FrnoattWV cmrvltd my Dot. <br /> atreMmaATION A.oUPRPA12 DAnca,PAYME�T TAYUMTTYrs RGoerr/ Cst�aKP <br /> Fel: <br /> RroO li „a <br /> lex;. <br /> ; eeta <br /> 4 <br />