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' Sat aquin County Environmental Health De, ment <br /> DATE , MASTER FILE RECORD INFORMATION"MFR GREENFORM <br /> U ' Io4 1a <br /> SITE MITIGATION&LOP <br /> ]wd 1Dt GA.Ed �2pt7 LUNIT IV <br /> OYIINERFILc:CbMP%wwTRFF0U.OWMOPROPERTY OWNER INFORNISs lmNr �w END E] <br /> PAOPEATY OayNea NUE ( <br /> End af l st M, LeIN 4. <br /> � r -�BuaMEsa NUE ',:::; EMAILAIwRE.v <br /> �..... S'Ibnl e/oi. 6;ilscoc At L Q//ex2 t��R�Fr ne�- <br /> -QynerHDmD_�-dr/M)��^�J <br /> _. fTL, I_ <br /> oft , BTATE 7 <br /> cA- 9SZv <br /> ONner McYYrq Addnsa<^,'TI <br /> MIMIIno Attdrwe City •STT G BWs Lp <br /> C.RPONa'.0 WDmou,E❑ PARTNERSHIPW 58 FEDAOENOY❑ o,-u05,141 <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMINT_VOLUNTMY CLeAtIUP_WATER QUALITY—HW PVELIIrrr INVliTiOATMNI LOP <br /> FACILITY 10 INVM ACDOVNT ID PRM QM AsarGNED MKOYEE LEAs AGENCY:EHD_'? RWOCB_OTSC_EPA_ <br /> �_7SIRS R� 9 <br /> FACILITYFILE CbMPEECETHErMaWMSBUSINESS IFACILITY/SITE BFaRNIATTtolac <br /> Is this a NEw8miness Loc;Anoti not preVfW$ly regulated by the ENMRONMENTAl.HEALTH DEPARTMENT? YE. ❑ No <br /> Is this An EKIsrmO Business LOCATION buta NEwTYPE of regulated Business? yes ❑ No rij <br /> BU.NE.eFAOaITYfa11E NAME <br /> ? �.Y bz WwE ysc GEwrirt Ara9 FuKw N�i.A't- iRvrCt ;Mz.,r Yk o4F.' <br /> 8nEA11twIEaD all guNNew PNONe <br /> 5go)A 5G I7AcLFLC Av¢. u!A A IA. <br /> Cm S'-rrr�.LC-tcf� STATE LPRSZU-T <br /> BOIIN.oPaWEVISOH DIsrmor LoctTexaCODE Rttit KEY] <br /> McNklg Malreas WOWrERERRVqm Pb RWAbCmtaae Attend n:corCare Of lhptlbmiy <br /> Malling Addreaa City STATE Zry <br /> SICCOM APNS CONMENT: <br /> TH1Ro PAll BIWNe INFot Complete H BiMng Party is different from Property Owner or Facility Operator identified above. <br /> j8- -NUE/" //�� Aderdlnn:esrCAn Of Nnpel»iM r �y <br /> \` *m V S PNoNE Ze - D G O <br /> "TAre "P <br /> Y� \\�C""I' IRTA'gOPRES far fees.and charges OYMER FACILITYIBUSINESS Tlniro PAR EhLuNG <br /> IfY @",mcnND ConIPUANCe ACNrvolVlrncUerrt: Line unJerOgnM Appkonl,rvlirythat lam the(Mna,OPaarnr,orAUOroNreJ Agerof tbh BmineU,alit l aeLntaltole!hale!!PEIFEE, <br /> r PLNKrrE.EPFMS/EM'CN.W.uea"r11OUAYCkiew's asundmed wbh this nperntian will be silica to me norm Mdras idenlipW ehuven the AamMTAnnnv for Hindle INw reraf,Mat <br /> all information provided on this application it tme and correct:sad that oil ngsabual naliviNa will be perfnnnal in..Td.rm wkh,ll nppli"ble SAN JOAQNIN C01NrY GNimnc<Cos.aI'dhr <br /> Sbndnrda.wi SPATE anJ/ur FmHPAL LnnT and Regulorinua.M the onderaigned mvner,operator,ar agent of tlm properly bead at thoabove farihryhile eJJmr,l hereby authorize th<nkae of <br /> Y and nil raulT and NTcima.Eld iarnwmml infmu...11.a SAN JOAQVIN COUNTY ENVIRONMENTAL IIEALTII OFIARTMF Tae anon av it I.available and al the sxme IMu•it is <br /> /�dy'nvMed 1.Inc.,mY represenativo. /rt1 <br /> \�ry APPLICANT NAME(PltnsE PRINT) /F.� 41-ed SNrr1ATu@E. lira' �__ <br /> pt{c TITLE �• TA%10# <br /> r - -- <br /> A ..d. Ual. AvownilOMc.P,...!" leade wa /�� <br /> SITE MnIGATIO. ANOUNTPAID ORCWPAYMEM PAYMENT TYPE RECEIPT. CHECK RECEIVEb BY WOpN PUN PlE/7 <br /> FEE:f �C 1 <br />