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Sanoaquin County Environmental Healttooartment <br /> DATE 9/2—�2 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> 1 ( SITE MITIGATION& LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# OW WV�✓IG/ CASE# SQ�� SG'f 9 UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOW(NG PROPERTY OWNERfNFORMA TION: CHECK/F OWNER CURRENnYONF/LEWIM EHDEl <br /> PROPERTYOWNERNAME /ylgwr�cc BsnSon (ZCj) q 3 .yOf <br /> < Flat Mt /�. I Last PHONENumsan <br /> BUSINESS NAME T An .wel WN, CA ��s'IAfPC. E-a Vr-"&. <br /> CUDtky 4-Stn w on 5` ErMAIL ODRES ben onoeL,rII <br /> Owner Home Address I <br /> city <br /> $ s o �,,y,� Ro T1, R.00. <br /> STATE zip <br /> OwnerMallin Address rY <br /> T/N% En✓. v, QranP/ DLA �nSfw�, 5� mrf at S.n —To,-2o' Gf, /fOLT g . /�.B y*14t2, T(pPr <br /> Mailing Address City P, O r Sox k+0n State � /� Zip 9 5Zq ` 0130 <br /> r X16 cool s ko� V��rrIII <br /> CORPORATION El INDIVIDUAL❑ PARTNERSHIP❑ FEo AGENCYK OTHER❑ <br /> SITE MITIGATION_ENvIRON IENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INV# AccOUNTIO P RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_ PA <br /> RWQCB DTSC_E _ <br /> ubo- 5c if <br /> FACILITY FILE COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE fNFORMA TION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No IX <br /> Is this an EXISTING Business LOCATION but NEW TYPE of regulated Business? YES ❑ No 09 <br /> BUSINeWFAOILITY/SITE NAME b q. T / „ <br /> SITE ADDRESS kJ J�J�4J� SUITE# B 0PHONE�� r W1,S– <br /> CITYSTATE ZIP 015-330 <br /> L m,. 1-4 CA <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address HC/FFERENTIMM FMA&Addrfe^ss� �I Attention:or-Care Of(opfbna/) <br /> Aff4 : £n✓, Su'v. 131, a DL& ynS1-0, Sw t w+ S.., 5otiy ,� £ct 4065' bl 16B #lta,,F/.ar P,O, 8.- 96 <br /> Mailing Address CRy � ^ � .1 ,,` srATLA zip �'Lq 6—013c 3c <br /> APN# <br /> SIC CODE lab Du 1 COMMENT: f <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME I I D S 4p r p o r-ta, b•. Attention:orCare Of(ophone/) <br /> V 7�, tom` r�' fro rtSQ. <br /> Meiling Address .zg �Lo Ga'k-ti/ dabs Dr, S�- - 30o PHONE <br /> Cm I STATE l/.^M,,. A GJ LPP <br /> BGFBLM:ADORE88 forfee,and Charges l� OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the OKwer,Operator,or ARfhor¢ed Agent of this Busin Imow a PER,Mr FEES, <br /> PouvtLnES,ENFORCEMENT CHmGAs and/or HouRLY CRARGES associated with this operation will be billed to me at the address identified above as the AcCouRTADORess for this site I also cerfify that <br /> all information provided on this appliermon 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 STATE and/or RDERAL 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 JNVIRONMENTAL HEALTH DEPARTMENT as soon as it u available and at the same time it is <br /> provided to me or my representative. _/_ p y/ i ,r <br /> APPLICANT NAME(PLEASE PRINT) r Q/A'I'TT/� 44 A.-r� f''be- SIGNATURE fb-Y V`/ �(yVJ'—� <br /> TITLE S tT S.{ I ` CTI" 43'1 TAX ID# <br /> Approved By <br /> Data 11 Ao....In,We.Pro....Ing Completed By 1 Data <br /> SITE MITIGAT N AMOUNTPAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVEDBY WORK!!PLAN PE <br />