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SA.-—OAQUIN COUNTY ENVIRONMENTAL HEALTH DL- _.ATMENT <br /> DATE lz�jl Z (MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> CNwaED AREAS FOR EHD USE ONLY OWNERIDN LU (JV`�,J lI I CASE SQOO�j�'J'�� UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER(RESPONSIBLE PARTY INFORMATION: C CmE(cKiroKwERIS04YrRENnravflLFWrrH EHD(� <br /> PROPERTY OWNER NAME ��,' � CJ i✓1 /' \zesh 33 3 -LAS ux-) <br /> FIRST LAST PHONE NUMBER <br /> _ E-MAIL ADDRESS <br /> BUSINESS NAME fve—/ <br /> OWNER How ADDRESS •^� .�/cit/ -2, J./ <br /> CITY J 1)r G!l STAG`- LP <br /> OWNER MAILING ADDRESS <br /> MAIUNO ADDRESS :17Y �.,{ STATE LP <br /> ❑CORPORATION ElFLl <br /> ENINDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGCY RESPONMBLE PARTY El OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT 4 VOLUNTARY CLEANUP_WATER QUALITY/_�HW PIPELINE INVESTIGATION_LOP <br /> FACILITY IDN INV# ACCOUNT ID PR RO N ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB_DTSC_EPA_ <br /> 2-11.z3 -7 0 jd Idfvrl <br /> FACILITY FILE:COMPLETE BUSINESS/SITE1 PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YEStIc❑xpgNo ❑ jar(ct Sr <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES t . No ❑ �J <br /> BUSINESBIFACILITY/SRFRROJECT NAPE 5Z 7 3(,, <br /> SITE ADDRESS I PROJECT LOCATION `-. ve SUITEN BUSINESSPHONE <br /> L.m ^ STATE LP <br /> BOARD OF SUPERVISOR DISTRICT LOCATIONCODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS I I // ATTENTION:ORCARE OF(OPr/OK4L) <br /> MAxjw AODREssCm STATE ZIP <br /> SIO CODE <br /> T-APN# COMMENT: <br /> 64 sal/.,tz /��t,�e! 5e✓V(cC <br /> TNIRD PARTY FILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAIL OdLi <br /> ATTENTION:ORCARE OF(Ou'•IIONWL) <br /> 11AILM40 ADDRESS���5 /)-7�'Y V�✓Til /�}Vj�� ✓/� PHONE2/) `'VC^„�' G�1U.,1,10 <br /> CITY ` `T� ., �/�YJI C� I!�"1-'> STATE /p � 700/U <br /> ACCouw ADDREBa To SEND FEES AND CHARGES: OWNER[--) FACILITY/BUSINESS❑ `THIRD PARTY BILLING <br /> BILL LNG AND CONIPLL&NCE ACKNOWLEDGMENT: L the undersigned Applicant,certify that I am the Ower,Opeatar,.4uborL-M Agtn4 or Respoasible Party and I sclmawkdge that all PFUOT FFEt, <br /> PFA'4LTTES EATMC:MWC"GET and/or IIDLRLT CH4RGEf associated with this project will be billed to we at the address identified above=the ACCDLTTADDREYS for this site. I also cerftiY that all <br /> infa-mation provided or,this application b true and carred;sad that all regslated activities will be performed in accordance with a9 app6nble Skrq JOAQIRN COUKIV ORDIK4NCE CODES au&Or <br /> S rAR'DARDS and STATF.an&w IYDE AL Laws sad REGULATIO,NL As the undersigned 0,—er,Operat-,.4 tk-4aAga;arR ipoasbk Party for the project located show under faeflity/she address,I <br /> hereby auArorim the rekase of any and all remltr,repots,and other eavhoomes.h.l assessment i&'OrmaII=to SAN JOAQL:iri COUNTY F-N1TRON%MNIAL HFALTH DEPARTNmYI as Som as it is available <br /> and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) �17 3KMTURE I '� y <br /> y /v <br /> TITLE �i/ (�Lt>/o;-'j� <br /> TAX IaN `/, , 7 �O j <br /> APFROVm BY OATS AOCOMMMe OFFMPROCESMKICOMFLETED BY Cr! t� DATE <br /> SITE MITIGATION AYOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# 9 CHECKS RECEIVED BY WORKPLAN PE <br /> FEE: 375 375 1Z II 12 ELEC �U ZSU� EcL� �T�o <br />