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San Joaquin County Environmental Health Department <br /> DATEEE <br /> MASTER FILE RECORD INFORMATION"MFR" GREEN FORMEI- <br /> SITE MITIGATION& LOP <br /> BHa . NO o' OwNERIM <br /> C "• Si�f�orS UNIT IV <br /> P0�Hwn*Addnwu, <br /> FILE:COMPLET1ErHEF tLowivGPROPERTYOWNER/NFORtArION. ORFcrsoOWNERO~47Ey"RLFW"END <br /> � <br /> OwKUNAr <br /> FYI Mi <br /> Last <br /> NiOMENUr <br /> F•IML AooK[ua <br /> City <br /> STATE Zlr <br /> Divisor me]Nrtg Addteoa <br /> MWatg AddmaCKy <br /> ate% Zip <br /> CoaeoRATwN❑ IHDmwtAL❑ PAIr111FAatUP❑ Fw AoEscy❑ <br /> OmeK❑ <br /> >9Ti!NNfr1OAT10N_HINRONYBrrAI ASSRsgaOrT VOLUNTARY CLEANUP—WATER QUALFFY_HW PuncubiR I <br /> NVRBTppT10N—LOP__ <br /> FoWuJT'IOS t1Ve NAccount IP ROs <br /> ¢�O AEr.ENDRQCB211 O —V—OTBC_EPA <br /> FACILITY PITC COMPLETEW7 <br /> NG _ <br /> BUSINESS/FACILITY/SITEINFORMgnoAc- <br /> Is this a NEIN aueirlatea LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No J9 <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regula(Bd Business? <br /> Yes ❑ No ❑ <br /> ewrEmaRACKmietreNArE LtnCo h ¢T, 2c Etivlf`o'tltmevl 41 'Rom t4, ioh 'frL1S <br /> enEAonsese west QeY)�aI,Tt%111 O An (7'2. LIS u.c.j Ac¢ <br /> BURET BUNNE98 PttonE <br /> CrTY 9toc 'foh <br /> STATE Lr <br /> MCKy <br /> Rperwcr �/FFERENTewn F--A, drags I Nilan / 4 (� 1nftnUn.arca.«fupRN.9 3043 Gadd L1X71 "��. �a'! Ci DV h c" UvaC TATE L. n5,6�O <br /> f� JAPNI <br /> CasatENr; <br /> THIRD PARTY BILLING WFO:DComplete if Billi,L\Il/\ ng Party is different from Property Owner or Facility Operator idem ed above. <br /> 6UBlNF9a NAPE A I'c A w <br /> yam. � Atlentl «fops <br /> on:orCara <br /> Mailing Addresses aDoo 10��1` �1. /�n Il / //r^�Q6C PHDNe—qu)-6sa— LJ5V6 <br /> cm 4-'muyVI�1Q WATE GA zipq4(p(7b) <br /> ACCOIZATAWsw for hes and charges OWNER FACILITY/BUSINESS <br /> THIRD PARTY BILLING <br /> B,sat Ti AND CORcE A : 1,the under Sat Appgcant,re <br /> rdfy that em the Owner,operator,or Andesdred Agent of this Bushes;and 1¢koowled a that all P <br /> Pe,�-,U.ncc,E,�t'OR['cverr Cx sgces md/or Rourtrr Cx.sxces ussachted with this opendov wW be billed to vseuthe address idevd&d rbovr rs the ['MrmTndI at <br /> c E exvn£eF� <br /> all hhrmetlov provided ov this appgcatlov ts true and correct;and that ell re lPe"ScdWM will p A for this we. 1 a.certify that <br /> Co be erformed in ettordmce with dl applicable SAn JonpuLv COtnvtt ONhentt Coda and/or <br /> Stavdardr nod STATE and/or FEDERAL.Laws And Regulatlovs.As the undersigned owner,operator,or agent ofthe property located at the above fadiityisih address,l hereby authorise the release of <br /> Soy end all results and a rtro ennotal vveasvrm informetlon to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP RTMENT AS soon AS it b ave able ad al the same time it 6 <br /> provided to—or ivy represwar,r. <br /> APPLICANT NA ME(PLEAeEPRINr) �OL-� )I 1 ��_ I) (1���� <br /> iC l �II+aS){IOJ eroruTVRE �y-' U <br /> TITLE scVw9N GP1710`J IST TAX IDN <br /> Approeeei as Actsmftormosposeasolagcontplithol <br /> Serra MRroaTlox Data <br /> - AarotiNr PAW DATe or FAlypn PAYMENT TYPE RECDPT/ <br /> FEE. CHECKS REenat"ev <br /> WoRMPU//M PE <br /> LPo <br />