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San Oquin County Environmental Healtl4loartment <br /> DATE �b ZOII MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> _ SITE MITIGATION & LOP <br /> BtlaDEO AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOW/NG PROPERTY OWNER/NFORMATI w CHwmip OWNER cuRRENrcvoNFaewinf EHD <br /> PROPERTYOWNERNAME Me.Nrsec I &a SOA, (tet) $a9 -LIG`,S <br /> First MI Lest PHONE NUMBER <br /> BBBIHE88 NAME /� 1� f rl0 O^ ��1 T l w,� rye �/'/Ar� SI � E-MAILADDREBB <br /> DLky 4•.-s ^6 T W SVT PFI sI <br /> Owner Home Address <br /> g s o � Ro A ?-0,. J <br /> city L,, (.,tor STATE C/'�A ZIP S 33 <br /> Owner Mailing Add �r <br /> N" £A v, resa Y. Q,rnn" DLA T7r�51*ej, 5•, orf' a4- SA.,. -TOLa1T 61" 11065jr <br /> OGS B . W? AGt _ r7vor <br /> Mailing Address City 0 / O Ox 1 1 „ State r /J Zip p c2q / O/ <br /> 'J �6 oalol s�-o�K TAJ CJAA�r7 -1 J b <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FEDAGENCYMI OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY HW PIPELINE INVESTIGATION_LOP_ <br /> FACILITY ID INV# AccOUNTID PR#IRO# ASSIGNEDEMPLOYEE LEAD AGENCY:EHD_RWQCe DTSC_EPA_' <br /> FACILITYFILE COMPLETETHEFOLLOWING BUSINESS/FACILITY/SITE/NFORMATlow <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO <br /> IS this an EXISTING Business LOCATION but NEW TYPE Of regulated Business? YES ❑ NO i9 <br /> BUSINEaWFAciuw/SRENAME V D —TC — S IYar <br /> SnEAOo eas So r! f] _ �'t Q 1 SUITE# B INEBS NONE <br /> CITY L <br /> I Jet Z r ISO r rl !�4 2oq 39 ��bS' <br /> ovr h v STATE zIP 01 s3 30 <br /> BOARD OF SUPERVISOR DIMICT LooicnoNCODE KEY1 KEY2 <br /> Mailing Address;KO/FFERENTfo FWNtyAddresa Attention:orCare Of(op#oneQ <br /> AflAt £Ar, - rv. a,. ek DLA <+.q. s ,+ 5. 5PV �r� EKr tines W IbB iiIcrj.F/.Pr <br /> Mailing Address City S� r .(_ STATE, ZIP <br /> Iv C/6e, n�h <br /> SICCODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESSNAME iz. <br /> s �rpor- Ab,� I - Attention:Orcare Of(optlanatV k. <br /> Mailing Address .Z(V e � 1q W � S p r• 5 y-c Soo PHONE ( I g V`� a!^�,p-,0 -4 / <br /> CITY JA C/rwlattw Ie STATE I! ^`� /1 zip (�/J O *9 3 <br /> BOFOLMAOOHEBS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,cerfify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMH I LIES, <br /> PiwA TIES,ENFORCEvavr CNMGEB and/or HOURLY CHd Gw associated with this operation will be biHM to me,at the address identified above m the ACY'oONTADDRESS for this site. 1 also certify that <br /> all information provided on this appfication 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 STAT 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 ANVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative D <br /> APPLICANT NAME(PLEASE PRINT) �/q'I'T'+f� OPS-,rb r'G2. SIGNATURE <br /> TITLE lk q 5.11 y Cr,Gel �� t TAX ID# (1 Ll 3 O <br /> 11 Approved By Deb Ammunfing Office Processing Completed By I t Data <br /> SITEMITIGATION AMOUNTPAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE:$ <br />