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San Joaquin County Environmental Health Department <br /> OATS 1 b -a 3-I MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION& LOP <br /> e <br /> OWNER[DO DWOO z��� R"'(,�o'y UNIT IV <br /> ONMER FILE:COMPLE7lE rHEF L(�OM/NG11PROPERTY OW NER/NFORMAT/ON.• CHecxn OWNER VimeeRnroMruewmr EHD� <br /> PRtmEaTYOwxER tiAalE �1'rry O SUN., I ) <br /> FI'W Mt Lest <br /> PIKWENIAMEq <br /> Bwmrse NAasE <br /> FYAL AooREae <br /> Owner Home Address <br /> CRY <br /> STATE LP <br /> Owner Mailing Address <br /> Melling Address City <br /> state Zip <br /> CO Zion❑ NIwYID1/AL❑ PNnNERwly❑ FWAGeNcr❑ OfNEA❑ <br /> Sm MITIGATION_BmvtRDNMEaAL ABNOWm rr_VoLUNTART CLaAAR ,_WATER QBALETe_NW FIPMJNE INvai r1BATNIN_LOP <br /> FAOLRTIDE Irrv1 �Rss��TTA,asouNr lD P ROs Aeatahm EIWLOYE LEAo AeowY:EHO_RWQCB�OTHC_EPA_ <br /> rl1W p D�z )3 joHrvrvH <br /> FACILITY PILE COMPLE7FYWFOLLOWAIGBUSINESS/FACILITYISITE/NFORMA7/ON' <br /> Is this a NEW Business LOCATION not previoWy regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No JN <br /> Is this an ExisnNG Busineas LOCATION but a NEW TYPE of regulated BmInes I7 YES ❑ No ❑ <br /> eWWERAIFAOM18"NAlre L.%ncb tC Gonftetv EhVIrDY)ISTQVI a1 R8 t4 it7n 'frlAS <br /> am"OR WecA %etfjS 4,'Tlt1 D � 17P+ � I'1'l7 4C4 surres BuRNOe PtIONE <br /> one, $1.00 �Oh <br /> STATE Lv <br /> Bongo of auvEnWORIksTNcr r LesO —=Cone I KEH Ker! <br /> Mailing Addreo fi`&ffERENTJh vo Fec/gyAddnee 11 I I Attenlbn:arcane Of(opansR/� <br /> 3ose h NALLr\ `` TIIr//L�s�Qe <br /> Get <br /> 1 Coh5u�10.nTs Inc <br /> Mailing Address City 3043 GoIQ Lalli Des a'l�Gt10 C oi,) C .gTnTE ZIP <br /> SICCtne J I APN0 ij `7 rJ tY <br /> ccasren: <br /> THIRD PARTY BILLING INFO: Comp <br /> T/ <br /> umele if Billing Party is different from Property Owner or Facility Operator identified above. <br /> Ghess NeetE 1a?,cAbD s Attention:O Cen Of(uPAws+fl <br /> Mailing Address Xv ,\ '2 . PE <br /> Cm 9000 ?L Si6- Ysa— LIBV,^ <br /> iS <br /> lrrn2cyV'I1\c GA npg9CDbb� <br /> ACf VATAOPREac feirfeas and charges OWNER FACiuryiBu5lNess THIRD PARTY BILLING <br /> &LunG AND CQ,,,MCE A : 1,the uodersigoed Applicant,cerdry Not 1 sm the Owner,Operator,or dudronyd Agent of this auWoesa,ted 1 askoowlydge Wat ell PAAHII'FCEs, <br /> PEvV rL r,ENFOACEV&W Cx,IAGFS eod/or HHUALI'CHANGES essocleled with fhb operation will be billed to vR ethe address i Authorized <br /> tl ent o th theACCen,t ed I etk for edu site. I also certlry thW <br /> Ali iorormetloo presided on this application b[roe and rorrttl;and that sU regulated activities will be performed io accordance with WI epplkable SAN JOAQMN COH Ordloaoce Codes and/or <br /> Standards and SfAW and/or hEOH Laws and Regulsfioos. As the uodrrsigoed owner,operator,or agent of the propertyNamed W tbeabove f=Wty/sire address,I hereby amhoHw the release of <br /> any sed W results end eotlroomental meessmeor iAformatlon to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP RTMENT to soon as It b availeble,aod no the same line it b <br /> pro�iclerl to ext,or my repreo,ittefive <br /> APPLICANT NAME(PLeAeE PRINr) �RpUaS6 <br /> 9KshATURe <br /> TITLE s cywo♦r G Q(7l0$lS T TAX ID N <br /> Deb OIRw Pica... Com ted Gsb <br /> GIlE Mrt1OAnON AMDaM PATO DATE OF PAYMENT PAfAlehr TYP! RECflPTd <br /> FEE:!] DHeDKa REOWlD BY WORK PUN PE <br /> I��/�OO <br />