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San Oquin County Environmental HealtlllmDartment <br /> DATE /b MASTER FILE RECORD INFORMATION "MFR" <br /> GREENFORM <br /> __ SITE MITIGATION & LOP <br /> SHADEDARFwa FOREHDUSEONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETE TNEFOLLOW/NG PROPERTY OWNEpR/NFORMAT/ON., CHEcKIF OWNER CuReSNrcroA,Fic wnH END <br /> PROPERTYOWNERNAME Ma,-r,-LG pa.n.So" (tdj) qTq "yObS <br /> t Fast r� MI /r��� / Last PHONENUMBER <br /> BDBINEB$NAME 1� f- pJ'I'rOn �A SP0. V� Vr �rP'lTtar�t 51 E' ILAOORE88 s7 <br /> D)..(ty V.S n p (� 1 M0.Vt•?CQ. bCnt:on oe t.Mr.Q <br /> Owner Home Address <br /> Di C, Lo fLrvr d STATE zip II C ^j30 <br /> Owner Mailing Address rIu 1 / `�� /bg /TI4$j,, rttAar <br /> �J"N% CA V. V, Qi r0.A f/�r �L A 1=n•S/w�, Or l a'r rin -T00. Nil Gf r yot s B <br /> Mailing Address City P. p r O 0 x k 1 „ State ' Q zip 5-2-9 <br /> 2-9 L - OI <br /> s� a ll oc�p1 s-F,� "rD Chjn17 J _1 <br /> CORPOMTION❑ INDIVIDUAL❑ PARTNERSHIP El FEDAGENCYK OTHER El <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT-A VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INVM AccouarlD' PR#I RO# ASSIGNED EMPLOYEE LEAD AOENcv:EHD_RWOCB DTSC EPA_ <br /> FACILITYFILE COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE/NFORMATlom- <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No 1W <br /> IS this an EXISTING Business LOCATION but NEW TYPE Of regulated Business? YES ❑ No <br /> BUSINEssIFACILIrYISm NAME O L. T C „ S t��, !� <br /> S1 ADDRESS L8 JCO C�11 Q _ d'� a� 1 SUITE# B 2 q E3q -ribs, <br /> CITY JVL \1 L ISO 1 rr I`4 STATE zip Gj s'330 <br /> BOARD OF SUPERVISOR DISTRICT LOCATIONCODE KE" KEY2 <br /> Melling Address NO/FFERENTfrom F=1#t Addm" Attention:orCare Of(opWnal) <br /> ANAs £Ar, Skrv, 9r C4 014 kill. $ f 4065 61 16B 14C12*Fleor 9,0, g.+ 96 <br /> Mailing Address City ��^ l ,( STATEE ^ zip Gl S"Zg6—�!3 <br /> SIC CODE APN# I`'' CiEC rr COMMENT: C./7 <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME r 1 s r P o o.�-b^ Attention:orCBre Of (opfbnelf <br /> Mailing Address .Z n /' ^./. w rHO <br /> 5 30� PHONE ?—so <br /> I <br /> Clrr S A r✓�.., � A.K STATE l Q� zP g S 8 3 3 <br /> AccouyrA p@ESS for fees and charges OWNER FAciuTYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Appfica of certify,that I am the Owner,Operator,or Authorized Agent of this Business,and 1 arlmowledge that.0 PERM?FEES, <br /> PEXUTIW,ENFORCEMENT CHd GW and/or HOHRLY CHd GW associated with this operation will be billed to me at the address identified above on the ACCOuw,tnyRFSS for this site. 1 also certify that <br /> all information provided on this app&cadon is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUW CmM1Y Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time itis <br /> provided tome ormyrepresentative.APPLICANT NAME <br /> (PLEASE <br /> PRINT) 90,fT„aI-- p A-r� r'fA SIGNATURE ��f v ^ <br /> TITLE S+k4 Se{ I -�C,;"4,3 TAX ID# qy - 3 38y <br /> Approved By Date Acncun#ng OIRce Processing Completed By Data <br /> SITE MITIGATION AMOUNTPAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORK PLANPE <br /> FEE: <br />