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SanOlquin County Environmental Healttoloartment <br /> 99 IF GREE FORM <br /> DATE /Z-J 2. MASTER FILE RECORD INFORMATION MFR SITE MITIGATION& LOP <br /> SHADE D E Po EHO ONLY OWNER ID# OVV M/IZ�gln CASE# SQno� 5(,79 UNI IV <br /> OWNER FILE.COMPLETE THEFOLLOW/NG PROPERTY OWNER/"'NYYYFORMA TION: CHECK/F OWNER cuaaexrerGWnLEHy EHD� <br /> PROPERTY OWNER NAME 04 qv ricSOI Ld�� <br /> < First MI Last PHONENUMBER <br /> �1 1 / T /�e p(� E AILADDRESS /'� <br /> BUSINESSNAME - t1'r 6J'I'a0n SAA TO N. ✓�J � �S/Twrpt- 5t M0.V riCe.. 6enso Ali f:A•4,M,.0 <br /> b01, 4.s <br /> Owner Home Address <br /> CJ sTATE zIP S 33'V <br /> city L o-11t or C <br /> Owner Malling Address t Sen .Toa N}t £jLf, 4065 B . l6g n14tt, "ppr <br /> N: FA V. V, Qra^ D6A /��S,t�/'.tQE, 5Y" 1p'-f 4 <br /> Mailing Address City P. O . pot Q f7 fila' lj'1 OV� r� state ��/JI ZIP q52-,14 - 01 <br /> CORPORATION❑ r INDIVIDUAL❑ 6 PARTNERSHIP❑ FED AGENCCYJII[l�. OnIER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESESIENT-X VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACIUTYID# INV# Al COUN IO P IRO#� ASSIGNED /fAMM LEADAGENcv EHD_RWQCB DTSC_EPA_ <br /> Ubo ll, 2 J/ <br /> FACILITYFILE COMPLETE TNEFOLLOWING BUSINESS/FACILITY/SITE INFORMATION.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes ❑ NO tW <br /> IS this an EXISTING Business LOCATION but NEW TYPE Of regulated Business? YES ❑ No IN <br /> BUSINESSIFACILIYISITE NAME DJ 3-6 — 5Adr- <br /> SITEADDRESS 8 CO (! , SUITE# B 2��3 NE�� <br /> Cm JVc J L I`� 4 STATE ZIP S33O <br /> L q.71. rc <br /> BOARDOF SUPn <br /> LOCATION CODE KEYt KEY2 <br /> Mailing Addreac/l/lyAddress Atlengon: ak I Of(optbns/)A/�n : £nvf.1¢ �nsf./I, $v fi .� $�� 504 ✓r� Ecf 40LS 61 16B P1t2f /•pr P,O, 8.� 96 <br /> Mallltg Addre �� ^ [. .�� $TATF, ^ ZIP q Z96-�J3 <br /> SIC CODE APN#Irl .^v/F`�- O COMMENT: t../1 <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner o�Facility Operator identified above. <br /> AUantion:or Care Of (opfic-1) Imo r-,pSQ_ <br /> BUSINESS NAME I`� s � rP or-4,1(-,�7.. / _ /'� V`1 a <br /> V D r 5 y� 3O✓ PHONE 1 �> v I Z.D� I <br /> Mailing Address Z /J /' .1. W T <br /> CITY et Ca 'K- STATE,. ar ZIP � <br /> S0.rrb..-,t•,111, 83 3(J <br /> ACOQUIVIAOaH<x.B forfees and charges OWNER FACILITY/BUSINESS THIRD PARBILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Appfiunt,certify that I nm the O.Yo r,Opemmr,or Aw1u,naed Agrnf of this Buain , <br /> Imola Pexuff FEES, <br /> PENALTIES,ENPORGeMeNT CHARGES and/or HOURLY CHARGM associated with this operation will be billed to me,At the address identified above as the ACCouN ADDREss for this site. 1 elso certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and$TAW and/or FEDERALLaws and Regulafions. As the undersigned owner,operatoq or agent of the property located at the above facility/site address,Ih city authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY JNVIRONMENTAL HEALTH DEPARTMENT as soon as it is avagabl and at the some time it is <br /> provided to me or my representative. �,�P 1� I <br /> APPLICANT NAME(PLEASEPRINT) TA'�'�"'" B p,,,rb r'G� SIGNATURE <br /> / <br /> TITLE ,L TAXID# qy^ 30: 38 <br /> s,�,� sy{ ' y�UI �� 1 <br /> Approved By <br /> Data AccoundnB ORoe Prooeaaing Completed By Data <br /> SITEMTTIGAT NffAmoUNTPAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORR�ONPE <br /> FEE:$ <br />