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05/21/20.12 07:30 FAX E3503651' BafC BOB 10002 <br /> ?-k r T <br /> San Joaquin County Environmentai Health Department <br /> Dire I�- � �rZr MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> a.l...�. ._L.,17a t?teo l�aEQlILy tWHo ta+1 caEr Sp2�o G.y9�o UNIT IV <br /> OWNER FILE WOMPLETETUEMLLOWAFGPRO PERTYOWNERINFORMATION: CwnefrfrOWNERQuxmiwtravRterrnxEMD <br /> pleornn^rt�yvNaaNaate P obe✓ k'i S 5 0 (slo - y0oo <br /> First w+l Lasf PwONENuawot <br /> BIMM mNlWa I s.+d o Av-0,o v-L LL G- r '1SrOt�lf wa mec�un�4� C�l''I <br /> owmar Harrm Addritfin <br /> - BYATr'fA <br /> Owr aw hHd IIn1Y Addnu <br /> Ma3Nnp Addrsea Ony Bln�a ZIP <br /> CDurOPATI(M IN10MMAL❑ PAttTrtmattlr❑ FED AWACY oTltta Com''" <br /> >$1T11 MIIfi1a11TWH_MNVIROHAIIIINTALAMagMWr ZVOLUNITARY CLOWUP_WAT■t Q UAU Y_HW PLOELIDIIIII IltV=1M1WN_LOP <br /> fAoltJrr ID IM Itty� AvoPt+tri lD PR 0 f ►w+�o Frirtai�. :.1 r.n Ac Nast ENDOW—DTC�. EPA— <br /> las� 1'2-9 I 4 o50L 3LDf <br /> I-ACILI7Y FILM eo mPLE7FTHEFOLLoWXNd BUSINESS/FACILITY/SITE/NFORMA770N.- <br /> la thla a New BuOr"a LOCATION MtprayiotnlY r@guiwtlld by tha Eh MOt M MAL HILALTH DEPARTMENT? Yw ❑ No ❑ <br /> Is this an EXWMQ Bttaftteha LOCATION but NNFWTYPe Of r@QUWW 64sind`W? Ylts H— NO ❑ <br /> BUM LBDlMAOaJrylSrnf NRME <br /> arteADDKt�s eurnif I3tMINaffP1101tt: <br /> CATS U. S33t7 <br /> BOA"OF&.1rerVataa DtaM=r LOOATSOH GOoe! Kt:T1 Km2 <br /> Mrd4tp Addrvas,ffaaj mwvrftm0wcaYrAaHtsaw Aabntlon:orf ars Of(t pJknafJ <br /> STATE 7511 <br /> FMllln l Addre"rlty <br /> BIO com APN d CCa111iHT <br /> THIRD PARTY BILLING INFO: 2REEWBA(Silling Party Is drfrererrl from Drupe Owner orFacil (Operator Identified above. <br /> Owaiaxv NiAra jec' ` � Atlw,ttwr.otrC+r•�(wl�'�vac 17 5'rcm uG� <br /> MaNhrp Add(Ma O to Noe, I/$ >L S�r ti-,Yc 4 d <br /> Crnr STATE�� �► !�S J 1 <br /> for rad ohear'pu OWNER FACILITYIBUSINES3 TtaftD PARTY BILLING <br /> sa an <br /> 61�uNG AND oAtruANC6 ACfCUOWt.[Dcnl[M'_ 1,the.nderalpied Applicant,certify that I am the otvndr,Codeoxr,or dwdtoriaed.49ont of this BYsintN,and I AKIwoAtdgt that.11 PZNAfrr FiFfs, <br /> P9NAMYS,ENFORca IOTCHARCM Andlot'HOUR0CHAWIS■ssocleted with this operation will be billed to tat at the address tEentllfed above as the ALCOrm�ADDtWtS for this dte.I.Ira certify that <br /> all Information prorldAd an this Application is true and correct;and that all re;ulattd activities will be perrormed to accordance wlth 011 applicablt SAN JOAOUIN COUtm nrdlnaact Codss.ndtoe <br /> Standards and STATL and/or FEDERAL haws sad Regulatlana.As the andcssigntd owasr,operator,or AYtat of the property located at the abavt ratlllty/ske■ddreaa,I hareby.atherUc the relrast of <br /> any and all mulls and gtironman(as aY9e69ment I.formadon to W JOAQUIN CUUNTY ENVIRONMENTAL HEALTH RT, Fa soon as It Ir ayAllod h Hme RIs <br /> projided to me or my etpraeatratre. 51 <br /> J� <br /> APPLICANT NAME(PUMUEPawl) I� 4 Y ,t L) G P t: 4 RIONAw r] <br /> TTnji /Y� J` a�rA&Arr/�� TAX{D 9y 33a3 ani <br /> OQ{o.Pennate td t1.r 1 v <br /> StTYMM0^710" ArouNTPwso DAT[ 11w'fndlT i•wriExTTM R'OdrT�Y Ct,aaKR RaAlvinBy <br /> �* 3 <br />