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0 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> [��yyry SAROO� yv SITE MITIGATION&LOP <br /> BxAneo AE no USE ONLY OWNER ID/ OlJOOI U - I U S2oo("EF <br /> Q 0"e UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INF CwecrMowwarS CORAennrowncRmrw EHD � <br /> PROPEn}Y OWHEIR NAEE <br /> � Z— O <br /> FMA T MI LAST PHONe NuYseA <br /> BueINESS NAM <br /> FYAIL ADDR¢Is <br /> OWNEAHOIIEAWRIM <br /> z up <br /> Cm <br /> STATE LP <br /> OWNER Muuw ADomeat <br /> Muuw ADonm Cm STArz LP <br /> ❑CO MTION 'KINomouAL ❑PARTHIRsgP ❑OOVEANIMIR AowoY ❑RwroNSINU PARTY ❑OTNEA <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP_ <br /> FADILRYIO/ INH A000u.10 PRNRO/ AEeNNEOEMPLOM LIUDAGMW:EHD�JiWQCB_DTBO_ — <br /> [FftO �Y-bSZv' A40404 �R053$ JuHRw <br /> FACILITY FILET COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCA TON NST PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES�' No <br /> IS THIS AN EKISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES Q NO <br /> ButINAMFAOlu1YAIITA/PAQIFOT NAT! <br /> erte AOORGAs!PRaeOr LoOATgN <br /> SUITE/ BUSINESS PHOHe <br /> CITY <br /> -602- O <br /> BiArz Lr <br /> s <br /> BOAnDMSUPERVGOR DRTRbT Lo TIDN Cove I REYI <br /> MAIuw ADoetus,IF dFPT11ENT/11p1 FACIDTY ADDRESS ATTENTION:ORCMs OP(G►rRAYeI( <br /> MMUNOAODRERSCRY <br /> STATE ZAP <br /> 810 CODS APN/ ZJ9 'Sio CCeMtOrR <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUAINIM NAYS 1 1 340 -". ATTDlRON:OADARE OF(OlreGYAe) <br /> MNuw AoDREAA FI 3yU"7-3 PHONE <br /> Dm <br /> Brnrz LE <br /> ACOouNTA0DRE8A TO SEND PFFD AND OHAROW: <br /> OWNERK FACILRY/BUBMESS[3 THIRD PARTY BIUWGO <br /> R I [ CO A--NOWLEDGMENri 1,the,mderciened A"Um eerdfy dut 1 em the 0rvnv,Op mom,Amhvr&AdAgvN4 or R AdhM <br /> ep0 Awry and 1 r for id[e that ell PHfy dNFas, <br /> PrwunsT,ENADRCGPA'rCNMG6 EEd/m JJODRLr CN.UGTS EundAted Mlh IhL prRJat will 4 haled m me EI We Addrvr Mmtlfled ebDSA u the ACLroDATADIMEO for"dh i AW nrtlh WAt RB <br /> Inforru'Im Pr M m Ab APpDntlm le true end emrem:end atal AO rejulebG AI"-MU he performed In Arcddmm x eb AD APPRlahle SAN JOAQUDI COIRYTY OADINMU Coon End/or <br /> STANDARDS ARI STATE Aod/m EIDTAAL lam and RECUunotG. N ebe mdenlpled ORRu,Opomrr AvehwiOdAlm4 w RoparoMle Awry for tlH prSJmr baled Above under 61iBryLIM Addr®,l <br /> hereby eudwrte Me reluee of ADJ EM All reAWb,nporq Evd Atlla emirorlmm W AYarome bforwlbR m SAN JOAQDDI CDNOY E! deAEMAL NGLTN DErAATAGNT u moo u It b vA <br /> oBA61e <br /> AOd n Ib♦--.1 Woe It M pr 16d to meer my repreemmdve A <br /> APPIJOANTNwwe(Pt zPRINT) <br /> IeJ, _ 565Zs�-/.rte <br /> 'm h' DATE AoOOUMOMo OeRq PEDCE1sW0CDIRR[L SY DATE <br /> StreMmDATyY AIIgONT PAq DATE OF('PAYYGHT P� !/ECYK R[a61nt CHGONS 7 REOetVP-0BY WORk PLAM PE <br /> Feer 37, 17� <br /> 708 <br />