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San i9quin County Environmental Health.partment <br /> DATE 9 — 'till _ , 0. MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR END USE ONLY OWNER IDN O\L IA f��C CASE P�0UNIT IV <br /> OWNER FI LE:COMPLE7F THE FOLLOW/NG PR0PERwTYVOW_N1ER✓1INFoRMATiow I CHEcerw OWNER cuRRENTLYoAFxEw"EHDE] <br /> PRDPERTYOWNERNAME J O VN N IIL.nd Tr TQe (%) (637- 116418 <br /> Fust MI Last PIIoxENtWaER <br /> BDaINE88 NAME II i� s \ I EiMILAD011E55 <br /> h(h n Cly vor ��U1�aRM.Q,nTee.1 1ZQ�hQ ,�- Li,f,TV kA4 <br /> Owner Home Addr <br /> city STATE ZAP <br /> Owner Melling Address 3013 Gadd Ca�a.� 16r. Su.,, Zb I <br /> Mailing Address CRy 1�1J\I GR() Cor�o�Q Stab ,r Zip '?SOL) <br /> CORPORATION INDIVIDUAL El PARTNERSHIP❑ FED AGENCY 0 [OTIIERIW <br /> $ITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELJNE INVESTIGATION_LOP <br /> FACILITYIDN INV# ACCOUNTID PRN/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHDRWQCB 2�—DTSC_EPA_ <br /> 00 77 7 r 1 1�j Poo yoc7o3 JoIiNW <br /> FACILITY FILE COMPLE71F7HEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMAT/ow <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO <br /> IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No ❑ <br /> BUSINEss/FAcu."ISRE NAME Lvnco�\\ IMag, S` Dpp,h GY n, -e\ <br /> SITEADORESS i�4k C`(1 ��`C 1 j Qj m v \V G„���S�l• �1�L SUITES BUSINESSPHDNE <br /> CITY J�DG\\TG\ONNY� K•Yl(/Y STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT 2 LOCATION CODE I KE” KEY2 <br /> Melling Address/r0/FFERENTNom Fac/UlyAddress AUenlion:orCare Of(opt/one/J <br /> Melling Address City STATE Zw <br /> SIC CODE APS# 2A q COMMEwr: <br /> TNIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINEsSNAME -�I( 17r�GA(),S IS• 1 n C Mention:crCare Of(opfbnaq <br /> Melling Address /A000kVbOW 7}" 7ooP PHONE 5lcO-Casa- k1 <br /> coDO <br /> CITY I— QC,1 IS Ac Y STATE C^ ZIP Q LI/COe <br /> A(N�/AVANGRES4,forlY <br /> fees <br /> charges OWNER FACILITY/BUSINESS THIRD PART( BILLLING <br /> BILLING AND COMPLIANCE ACKNGWLEDGAIF.NT: 1,the undersigned Applicant,certify that I Am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that 1111 PERMIT FEES, <br /> PEvaEnEs,ENFORCEVEnT CaaaGes and/or Hoe'uv CHtacEs associated with this operation wig be billed to me at the address identified above as the ACCOL:NTADDE for this site. I also certify that <br /> all information provided on this application is true and correct;and that all regulated acuvifies will be performed in accordance with all applicable SAN JGAQuw Cou 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 fm11tty/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT As soon as it is available and at the same time it is <br /> provided to me or my representative. Q , 1 <br /> APPLICANT NAME(PLEASE PRINT) � Z)V,U� 0100-SI f� SIGNATURE <br /> p�,., (` �1 /r \ <br /> TITLE �u I��r l7 Q,rJ10f{�ST � NRCK'D IS TAX ID I <br /> Approvetl B Date I Aeoounfin OIRee Proaeming Completed By Date <br /> SITE MITIGATION AMOUNT PAID DATEOFPAYMENT PAYMENTTYPE RECEIPT# CHECK RECEIVED BY WORK PIAN PE <br /> FEE:; /I rT�O <br />