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San . _Aquin County Environmental Health apartment <br /> DATE =1 MASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> S SITE MITIGATION&LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE if �^ UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOWINGPROPERTYOWNER INFORMAT/ON. CHECiKIFOWNER CORRENTLYONFILEw/THEHD � <br /> PROPERTY OWNER NAME -'F• I An ,055' <br /> First MI Last PHONENUMBER <br /> BUSINESS NAM E-MAIL ADDRESS <br /> � F", Lwncl dtsol.L_ 1!S T(OL 6w a Dry-, <br /> Owner Home Address <br /> OS WeSfi �1Y1 ��hZL� <br /> Cityt-o 1 $TA� ZIP <br /> � C1 1• <br /> Owner Mailing Address LlL <br /> ,f o S Wk.sF I tt-mr Mailing Address Address City tate Zip <br /> (.od-► � 'j 5'2.4 v <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INV# ACCOUNTID (P11411 RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB_X_DTSC_EPA <br /> 3 <br /> �F5 Z7 O �o�NUy <br /> FACILITY FILE COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No x <br /> Is this an ExISTINO Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No K <br /> BUSINESS/FACILITY/SITENAME rr —2irvIGeS <br /> rm <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> CITY ' SZIP <br /> r r <br /> I 96.314- <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE O J KEY1 FEY;] <br /> Mailing Address ifDIFFERENTfrom Facility Address Attention:orCare Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of(optlonal) <br /> .F Lqn o �oW I G� .Ls o I t�,... <br /> Mailing Address W PHONE <br /> CITY STATE zip <br /> 9 57-4 D <br /> uNTAaoREss <br /> BCCofor fees and charges OWNER FACILITY/BUSINESS Com+ THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Ou ner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERdfT1'FEES, <br /> PEN.ILTms,BNFORCEALEAT CHARGES and/or HOURLY CHARGES associated with this operation will be billed tonic at the address identified above as the ACCOUNTADDRESS for this site. I also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance iiith all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE 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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) ©k OPS SIGNATUR <br /> Tax I D# <br /> TITLE &V, 1n17�<Ct <br /> yt"_ <br /> � � G( r <br /> Approved By Date Accounting Office Processing Completed By Date <br /> SITE MITIGATION AMOOUUNTPAID DATE OFyP,AYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE: �� J�s I �II J 7j �'/ ��%' (tel i` 6 <br />