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San Joaquin County Envivonrnen•tal Health Depaili-hent <br /> JATe MASTER FILE RECORD INFORMATION""ria GREENFORM <br /> SITE UNIT <br /> I MITIGATION <br /> IIp\\ta�t�LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER 1130CASE I! .m(�I Z / V NI llII V <br /> OWNER FILE:COMPLETE-Ulf-FOLLOWINGPROPERTY OWNER/NFORG9ATION: CnecmFOWNER CURREIIrzroriF11CivlviEI-ID <br /> � <br /> PROPERTY OVJIJER NAME '.{— I nn acv-7-- 705S' <br /> 11 <br /> First MI Last PHONENUMBER <br /> BUSINESS NAE-MAILADDRESS <br /> ZI- c-{- <br /> ",§l.r, LUrI Utsolw, � 150(CL law . eCr-e-) <br /> Owner Home Address <br /> b 5 �nle sfi �t n S=1 ��- <br /> city STATE ZIP <br /> A <br /> Owner Mailing Address <br /> '-E 0 S " <br /> Melling Address City d od" Zip <br /> 'JS24 L) <br /> (. I '"i <br /> CORPORATIO:4❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITU.MITIGATION_ENVIRONNIENTAL ASsESSMEN T_V/OLUNTAPY CLPANUP_VJATCR QUAIJTV_C 211 PIPELINE!ItJVVSi"IGATION LOP <br /> FACILITYIDi! INvIS ACCOUNTID PRI?/ROTI AssIGNEDErAPLOYEE LEAD AGENCY:EI'ID_RWOCB_DTSC_EPA <br /> _ <br /> ht�01� 1 u 57 6 1�� COMPLETEFOLLOWING BUSINESS/FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONtiENTAL HEAL it-I DEPARTMENT? YES ❑ No� <br /> Isthis his an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESSIFACILITY/SITE NAIAE _<ku l c e 5 <br /> r r rm <br /> SITEAODRES9 SUITES 13USINESS PRONE <br /> Clry � s�T,F, zip <br /> 1 �1 <br /> BOARD OF SUPERVISOR DISTRICT LoCATIO14 CODE \ ICEv'1 ICEY2 <br /> Mailing Address ifDIFFCRCNTFron Facility Address U Attention:orCare Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN fS COMMENT: <br /> THIRD(PARTY BILLING INFO: Complete if Billing Pally is different fr0177 Property Owner or Facility Operator identified above. <br /> BUSINESSNAMEr / ` - t -r" ARentlon:crCara Of(opl/onal) <br /> Mailing Address t t PHONE <br /> `-t 0 ' tr <br /> CITY L Sis" STATE- ZIP�j <br /> AGGDILACTADDRFS4 for fees and charges OWNER T FACILITY/BUSINESS 1..1' THIRD PARTY BILLING <br /> BH.IJING AND COIIPLIANCF.ACICNOWLEDGMENr: 1,the undersigned Applicant,ccl9ify that I am the Omer•,Operator,or.lydhori:,crl,hent of this Business,and I acluroidedge lh rt all PER.IIIr FEES, <br /> PEAALTIES,GA'FGRCE,IIEM'CHARGES and/or HDURLYCHARGES associated wish(his operation will be billed to me at the address identified above as the ACCOUNI'.tUDRL•SS for this site. I also certify that <br /> all information provided on(his application is true and correct;and(lint all regulated activities will be performed in accordance with all applicable SAN JOAQUIN Coutrry Ordinance Codcs and/or <br /> Standards and STATE rind/or FEDERAL Laws and Regulations. As she undersigned owner,operator,or agent of the properly 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 ENVIRONAIENTAL HEALTH DEPARTMENT as soon as it is available and at the same lime it is <br /> prodded to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) —.1fo�Y� CGOPet SIGNATUR- - <br /> TAXID0 <br /> TITLE C_ nTO"- C2 < ' <br /> Approved By Date Accounting Oftice Processfng Oompletod Dy Dale <br /> SITE MITIOATIOB AMOUNT PAID DATE OF PAYh1ENT PAYM1IENT TYPE RECEIPT I/ CHECIt 1t RECEIVED 8V WORK PLAN PE <br /> FEE:�.�� /y 6, <br />