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0 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE MASTER FILE RECORD INFORMATION"MFRE` GREEN FORM <br /> SITE MITIGATION&LOP <br /> BNA...AN.,10.END UIE ONLY DWNIR ID/ UNIT IV <br /> oA.[/ <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CxaGTra Ow—a CURRENRYONR,,,wrN EHDEl <br /> PROPER}Y OYMG NAPC <br /> FAT MJ usr PHONENUMEER <br /> BUSWEU NAWE <br /> ♦ [-1MIL ADDREEa <br /> OWNERNMEADORU/ <br /> Cm <br /> STAT! LP <br /> 01YNen MYUNo ADDRUa 4s <br /> MuuNa bones Cm <br /> BTATa LP I <br /> ❑CORPDMnoN �INOMDUAL ❑PARTNERSHIP ❑OovGNsesim AO[NOY ❑RIMPOMSHLE PARTY ❑OMER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP_ <br /> FAOIUN IGS INH AOaoum ID PR/IRO/ A/aIONED EMFLQM LAD AGISIOY:END---JiWQOB_DTBO_EPA_ <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION M PREVIOUaLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? Yee Jg' No <br /> Ia THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORN? YG ❑ No <br /> BuapEsalFAOlurrlSmlPRouFm NArc <br /> 8Rl bpREaal PRwcm LOOAnOM SUITE/ BUYN[aO PHONE <br /> om <br /> STATE! LP <br /> yr <br /> BOARD Or SUPGFIaOA Dar War LOD4,T10NCOOF NeYd I(M <br /> MAILINGAoDRM.WWAUEW"MFAOIUTTADORUa ATT ctw GECM!OP(oP7sNW <br /> MAJUNO ADaRen CITY <br /> STATE LP <br /> BIO CODE AEN. <br /> CQISIeNr. <br /> THIRD PARTY BILLING INPO:COMPLETE IF BIWNG PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUMINUM NAY! ATTENTIoN:OROARC OF (OIIAT I <br /> Malum ADOR W <br /> PHONE <br /> Cm <br /> STATE LP <br /> ACCOUNT ADDREME TO SENO FEES AND CRAROEB: OWNS FACILRY/BUSINEBBO THIRD PARTY BILLINOQ <br /> DG NdeNlEnd APP11=4 curtly date Ism the Owner,Oyvvlor,Aurhor@d Agm4 or R ru1S4 <br /> rthe 1wA , I AdooMedp dtiI d P df, Fars, <br /> PlNLLn6,£NFDIK'[gGTCNMe6 tod/m gODUTCNARcrs aualAlgid MIL tly proJIRI MS b hEled m me a Me ddrvl MmtlRd above u the AttnunTADwEO foe tl>b tlm 1 aW ardfy tlui W <br /> Informa on lnmv lyd on"aPPEndee Ie bate And e.rrvvtt And dal Ail re[ulatd aedWdne R111 be Ind.lmd Is Auordanm MIb W Appdnble SAN JOAQOEI COUIT'OROINANu CODU and/or <br /> STANDARDS And STATE ad/ar FEDUAI,lawn And RECU"TIONA Aa dH mrdemiPld Owes.OPermrr,.lufM1-HWAEen4 or Rerpom/dk Pmb rer dre P-Jeal I.W above i adu I rfligh oe ddry l <br /> hereby audwris gibe rehire of an,and aE MWq MPOM and other e=iromomMl mmmem Informadw to SaI JOAQUIN COUMY EI ONMENTALNGLTH D[PARTMENTY rare Y itb available <br /> And tl tlN ume dme it la provided In meet my reprummdve, ,Y/A/,// A T <br /> App? Nr NArre(PLEaaEPRINT) ��/ 1/C,t�C l L SIaNuIn IE / I 'l, — <br /> TInE <br /> To IDS SL]SZs}� <br /> APFaCVmh DAT! AOOOONIINOORRG FApCeaaGOCOIPL[rmh Dan <br /> 8Rl MmMATnN ArOVN1 PAJD DATe Or IAYYlHT PAYreHTTYI! RLODR/ CN[CN/ ReOEIVEp BY WORNP4N PE <br />