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• 0 PAYMENT <br /> San Joaquin County Environmental Health Department RECEIVED <br /> DATE S_ MASTER FILE RECORD INFORMATION EEMFR" I FJ Nil <br /> t <br /> Slfl T GA7 ovN&LOP <br /> AL <br /> ARIAMARENEQREKISAAEOBLY OINNERIDN CASE fT <br /> OWNERFILEXOMPLETETHEFOLLOW/NO PROPERTY OWNER lWoRMAwN: CHec/r/r OWNER CuRRENrLYomrxenani EHDF1 <br /> PROPERTY OWNER NAME <br /> Rod MI Last PHONE NUMBER <br /> BUSINESS NAMEE-MAIL ADDRESS <br /> L'InCo� n pro er �'1'�s LTD <br /> Owner Horne Address <br /> G 1 5 Li✓1 e a jr, L' e-y-?+p r <br /> Dlly STATE ZIP <br /> S h e < C A 9S-.2 a '7 <br /> Owner Melling Address <br /> Melling Address City state Zip <br /> CORPORATION El INDIVIDUAL PARTNERSHIP 1:1 FED AGENCY[I OTHER <br /> Sim MRIOATON_ENVIRONMENTAL AsSM"MENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVEsTIOAT oN_LOP_ <br /> FACILRY IDs INVM ACCOUNTID PRSIROS 1+ <br /> ROYOOO1234 ba a' 3r i„�•;snt 1 J`” (+ k <br /> FACILITY FILE COMPLETE THEFOLLOW/NO BUSINESS I FACILITY I SITE AfFORMAMN: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT7 YES ❑ No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUaINESSIFACILITY/SME NAME J(`etbing •T r r <br /> /T S <br /> SITE ADDRESS J, (J SURE# BUSINESS PHONE <br /> Cm STATE Zip <br /> -S+L)c k+b v, C Seo <br /> BOARp OFSUPEflYIeOR ONTRICT LACATIONCODE HEY1 REY2 <br /> Meiling Address WDIFFERENTrrom Fac111trAddiress AttenUon:or Care OF(optional) <br /> Mailing Address City STATE LP <br /> SIC Coos APNM COMMENT:50 � 03 U97+10 3 <br /> THIRD PARTY BILLING ll Complete if Billing Party is different from Property Owner of-Facllity Operator identified above. <br /> / BUSINESS NAME Attantion:orCare Of (opflonal) <br /> / c D <br /> Meiling Address PHoae <br /> CIT, STATE ZIP <br /> M <br /> cuY)ONr11ggesm for fees and charges OWNER FACILITY/BusiNESs HIRD PARTY BILLING <br /> BILLING AND COMPLIAN'R A(W O CMLNT: 1,the undersigned Applicant certify that I am the Owner,Operator,ar Anthorired Agent of flat Business,and I acknowledge that all PSRsnr Fats, <br /> PCNALr/rs,EN£ORUAIENI CHARGES and/or MarpLYCHAFOES associated with this optradon will be billed to me at the address Identifled above an the ACCouATADORESs for Uds site. i also certify that all <br /> Infarmation provided oa Wa ap,liead.n h true and correct;and that all regulated activities will be performed In accordaar.with ell applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. Aa the undersigned owner,aperstoq or agent of the Property located at the above facility/site address,I hereby emhurha the release of <br /> any and all rendts and en immuental assessment Information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as SSoo/n as it is availoble and al the came time it is <br /> provided 10..or my repraenmdva <br /> APPLICANT NAME PLEASE PRINT)l6a-c) GPF SIGNATURE <br /> � l-4,E�J <br /> TITLE fIp��D(S l T�D�rCi ? I V1 TAX IDn <br /> Approved By Data AacauMRS Moa Proasaing Complatad By Data ��tt�� r <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPTa CHECNa RECEIVED 9Y WQflIf,P,ylfla{ - <br /> FEE:$ <br /> 29os <br />