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San J( .lin County Environmental Health L artment <br /> DATE MASTER FILE RECORD INFORMATION 46MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> OW""100 CASE UNIT IV <br /> OBER FILE:COi11100u F JFf AXLow1AKd PROPERLY OWNER/NFOA*Ar10N.• CHEcx'F OWNER Ct,41IM r7LYONAILEWrH EMD�- <br /> PROPERTY otiiNIft NAME <br /> First !1 Ml <br /> Last PHONE Ntntept <br /> eIJSIrE36 NAME E-MAIL ADDRESS C �✓ <br /> LW r 4:44 ,4I,4 LoT a�L G a. � �µl:�s PA AiT�zv� <br /> Owner M hire Addmmn <br /> STATE ZIP <br /> owner MaMltq Addreee <br /> Sf; A �6 SPi��-SSG,,4 ZIP a6 a <br /> COMORA lworaoUAL❑ PARTNERSHIP❑ FED AGENCY❑ SER❑ <br /> &M MMOATWH_MWAROttMRAL Aesn l fr VOLUPrrARY CLMAWJP_WATM QUALITY_Mrll PIPEL NG 1wea teATmm <br /> _"W_ <br /> FACAL—IDa INV# Acmes 10 M11011 AssloNED EY OYEE LEAD AQENCY:EHD <br /> RWQCB_DTSC_EPA <br /> 0 5D SS1 Gfo <br /> FACIUW FIUE C0AFtE7E"ffAXL0WAIQ BUSINESS/FACILITY/SITE/11ii oRmAnow.• <br /> Is this a NEw Busk on LocAnoN not previously reptrdated by the EwROMMENrAL HEALTm DEPARTMENT? YES ❑ No <br /> Is this an ElssttNG Buakfess LOCATION but a NEW TYPE of regulated Busktees? YES ❑ No <br /> OUSW*—fFACkRYMM NAME F v 7rr7iF <br /> P / {-//-f�Z&Yft� F07-411;FTlfiC oil_ 60 ST,�i7ftl-✓ �. 17?— <br /> SfTE AolttllMs <br /> 76Y-1 ! �Ci I ((r SUITE ii &MINESS PHONE <br /> arr ST 6K a <br /> O STATE <br /> soAaowslrMRVIeoRDtsTwt r Lor:ATIONCODE KEY1 KEr2 <br /> NAM Address#AWRN"Ir#cw FiCAKynlabi em Atbr0m:orrcane Of(OPECtItt* <br /> 111011110 Ad*—City <br /> STATE LP <br /> SIC COOS Anti a <br /> T MM PAWY NLINO INFol Complete if Billin P is dil br0/7t from Property Owner ot-Facliq Operator idenbffed above. <br /> aNO*MNAME <br /> Go�v oGa Pfau i <br /> MaftV Adan.. Z S G Ivl,} GIRG4� P!N)NE <br /> Dm M <br /> / `n A-f40,4Y STATE /21P <br /> fbr few and OwVw OWNER FACILITY/BUSINESS THIRD PARTY BI <br /> BR.LING AND COMPLIANCE.1CwVAWI vnr_urar; 1,the undersigned Applicant,cenih that 1 em the Owner, rotor,orAeth <br /> Ops oriW,Igen of this Business,and 1 acknowledge that all ftR%f/T FEES <br /> PENALITEst E FOW E LAI C-H4-w;&v and/or N(xRt.r('NAm iss associated w ith this operation will be billed to me at the address identified above as the.jgot;yTAfor this site_ I also certify that <br /> all ishrmacon provided on this application is trove and correct;and that all regulated activities will be performed in accordance with all applicableSAN JOAQUIN CO STI Ordinance Codes aad/or <br /> Standards and STAT[and/or FEDERAL Laws and Regulations. _As the undersigned owner,operator,or agent of the property located at the above facility/site address,1 herebv authorize the release of <br /> any and ail results sod eavimentenral assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as won as it is available and at the same time it is <br /> provided to me or m}representative. <br /> APPUCANTNAME(PLEAVEPRiNT) <br /> TrnFS 9LCG",r TAx ID 9 <br /> Waved v Drka <br /> otdlo. CorniplialtiallillitDara <br /> MITAnoN AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT a all.ac a RECEMM& oast 'E <br /> IOjrv <br /> t <br /> _ - S-i <br /> are <br /> Lam/° <br />