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San .9quin County Environmental Health0- partment <br /> °"� 0 8`Zo 12 MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> U SITE MITIGATION & LOP <br /> 111:1699DAREAS FOR END USE ONLY OWNER IDNU CASE <br /> pp+7Q UNIT IV <br /> o\f�➢ ll " / # sr�`"�4sUrU <br /> OWNER FILE:COMPLETE 7NEFOLL11OW/NG PROPERTY OWNER/NFORMA noN.• CAASCMIF OWNER CURRE,YrcroNFaewnN EHD <br /> PROPERTYOWNERNAME C5 tl STh 8"( —on <br /> Feat Ml Last PHONENUMBER <br /> BUSINESS NAME _ <br /> E-MAILAODREss <br /> Owner Home Address <br /> city <br /> STATE ZIP <br /> Owner Mailing Address <br /> Mallirg Addreee City <br /> State Zip <br /> -------------------------------------- <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP E] <br /> FED AGENCY❑ O."fSD <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIpE1NE INVESTIGATION_LOP <br /> 111 i! <br /> FACILITY IDN INv# AccouNTID P RON ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCBX DTSC_EPA_ <br /> Svlr 203 �plfyrfy <br /> FACILITY FILE COMPLETE THEFOLLOW/NG BUSINE$$IFACILITY/SITE/NFORMAT/ON.' <br /> Fhis a NEW BUs{ness LOCATION not prmiously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑15 an EXISTING BUS{ne33 LOCATION buts NEW TYPE Of regUlatBd BUTS ses? YES ❑ NO ❑E89/FgCILnYISITE NAME I.5 Y1Cb h CQ(� Qf �hV1C6nmen 4 emQ 14, 10 t 'r45 <br /> SREAOORE89 <br /> Lt'ft ��k CQ <br /> � 9 <br /> SurcE# BUSINJPHONE <br /> Cm +oc �i�r STATE ZIP <br /> BOAROOFSUPERVISORDISTRILT LOCATION CODE / Kvl <br /> KEY2 <br /> Melling Address VDIF``F'E'R NT#RrnFaolN(yAtYdnaas yy <br /> JAI 1 r rA C Atfeldlon:orCare Of/opGMWI) <br /> /'� 1 1 ks�'ee deo h Cor�1A, a n,c. <br /> Meiling Address City STATE <br /> CJOIdX\Q1 Qr�vQCp(�o <br /> STAT ZIP SIC CODEAPNDOMMENT: <br /> G STKN -ROIJa� <br /> THIRD PARTY BILLING INFO: Comp/ete if Billing Party is different froP <br /> m roperty Own ar or Facility Operator ident0led abo ve. <br /> BUSINESS NAME ( (� AttantlomorCare Of /opawm/J <br /> Melling Address n("`rlrri L7tJ d <br /> I <br /> a000�bweMs1 PNDNEV`�yDal Lige) <br /> Cfry cq 1n 111 STATE CA zip nl,/_„rT . <br /> AGQ2AyZAeG/fERR for fees and charges OWNER FACILITY/BUSINESS 7i'T((d L�' <br /> THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the uodersigoed Applicant,certify that 1 am the Owner,OperMoq or Authorized Agen!of this Business,and 1 acknowledge that all PERMIT Fees, <br /> PEAALTIES,ENFORCE:VEATCHARGEs and/or RooaLy CnuGcs associated with thisoperation wis be baled to me at the address identified above as the ACCoUwTADDSEec for this site. I also certify that <br /> all information provided on this application is true and correct;and that all regulated tan ides will be performed in accordance with all appheable SAN JOAQUIN COUNrV 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 fadllty/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART T as soon as it is availa le and at the same time it is <br /> provided to me or my representative. s� <br /> APPLICANT NAME(PLEAeE PRI Nr) C�QK. /' JI t <br /> II lVl f. SIGNATURE � 1 �L i/ <br /> TITLE GeD 1SY [AXION <br /> 1` <br /> Approved B 1 Dab Aaeounane OIBae Processing Completed By <br /> Dab <br /> SITE MITIGA AMOUNT PAID DATE OF PAYMENT PAVMENTTYPE RECEIPT# <br /> FEE:f CHECK# RECEIVED BV WORN PIAN PE <br /> 2 %0 <br />