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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> OAS' `3 SITE MITIGATION& LOP <br /> I"E110 VAR ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNC/IEMN,OSYHERIs CURREHTLYOHFILEW?H END <br /> ERI RESPONSIBLE PARTY INFORMATION: C <br /> PROPERIY'OWNER NAME L"Cc`" -Wb ''� LI TD Q'. ('4) LI /IPTG p- I Zoo <br /> FIRST MI LAST PHONENUMBER <br /> 1 ` [-MAIL ADORE88 <br /> BUSINESS NAME S,.A T _ <br /> �4 y �7C Y*'"rc LD <br /> OWNER HOME ADDRESS <br /> CITY STATE LP <br /> OWNERMAIUNGADORESS <br /> MAiuWADDRPJISCRY �S�T;�, \-, STC LP� • 2� <br /> CORPOMTbN ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION X ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP_ <br /> FACNnID# INv# ACCOUM ID PRWRO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWOCB_DTSC_EPA_ <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS A N EW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES No ❑ <br /> SUSINEBNFACILT 1SRFIPROJECT NAM! <br /> \YN.CL:,VY <br /> EBBIPRWJ LOGAT SURE# BUSINESS PHONESMEADOR <br /> `,,Qcc' A� � ge,T" 0.YYAAT+ FIpN <br /> CITY I'G jpvtn Y� C:�STATE �P� <br /> BOAROOF SUPERVISORDISTRICT LOCATIONCOOE Kul KEYZ <br /> NAILING;ADDRESS.M DIFFERENT PROM FACILITY ADDRESS �7 ^` L� ATTENTION:ORCpRl OF(OPRONALJ yy� <br /> ZIJL�J "A"A a s 'f0.1� \ I ir31:Dc CA L.Lr. , I ' <br /> MAIUNOADDRESSCRY STAT! DP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PART'IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> ATTENTION:MOA OF(OPIAWNL)c1c L1n �Y tris"Sk <br /> BUSINESS;NAME S-y <br /> MMUMOAMMMSX35 o PHOT 424-237 () <br /> 52. Aorr.c� <br /> CRY, Sa -�� Cr 96%-3 <br /> ACCOUNT ADDRESS TO SEND FEESAND CHARGES: OWNER❑ FACILITYIBUSINESS❑ THIRD PARTY BILLING <br /> BILLING AND COMPLIANC9 ACKNOWLEDGMEYT: 1,the undersigned Applicants certify that l am the ORNer,Opentloq Au1hanaed AgcRA orRMassible A.Vand l acknowledge that all PEMLHFE£$, <br /> P£NALTT£$ENFORCEALEWCHARGES anNor HOURLY CHARGES'associated with this project will be billed to me at the address identified above as the ACCOUWADDR£SS for this site, f also certify that all <br /> information provided on this appBtation is true and correct;and that all regulated activities will be performed in accordame with all apPlicable SAN JGAOM CGIMTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEOEML Laws end REG17LAMONS. As the undersigned Gants Operaloq ANT/mri.aAgenA or Respassible Party for the project located above under facilityleih address,t <br /> hereby authorize the reteue of airy and all results,reports,and other envdraunrnml assessment information to SAN JOAQum COUNTY EYVIRONTffNTAL HEALTH DEPARTMENT as soon as its available <br /> and at the same time it is provided to me or my mpresemative. <br /> APPUCARTNAME(PLFASEPRINT) LInA Y fnµ'v fir\ _ SIGNANR! y1�CA�J� G—'�!�i <br /> TITLE l.9CO3I,0 IS� E�I'y1 TAKID# <br /> APPROV®BY DAMAODODMINGOFRCE PROCESSING COMPLETED Be DATE <br /> SITE MITIGATION AMOUNTPAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK RECEIVED BY WORK PLAN PE <br /> FEE:$ <br />