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0 0 <br /> San Joaquin County Environmental Health Department <br /> DATE11 11 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> BNAoeo AAEAePM END UMCNLr OWNEm IO/ OMEN UNIT IV <br /> OwllRFILE:COMPLETE THEFOLCOW/NG PROPERTY OWNERINFORMAflON. CHEIWIFOWNER CmRewnraysnEwrNEHO� <br /> PmJreRTT Orem NAme <br /> ffldt Mf Lott PNDNE Iellout <br /> BURINES$NAME \� �` E-WULAGGREss — <br /> Owner Homo Address <br /> City ISTATE LP <br /> Owner Mailing AddressZ # -zfp C <br /> Melling AddtwsClty \ Z� <br /> CORPORATIM0 �p INDNOWL0 PYr,I"3 P❑ FPn AtxNGY❑ OfeEA� <br /> 7176 wint",noM_EWJMWIMmMTAL ABepaMB1T_VOLUMTART CLSORM_WATM QUALnY_NW PWUJN E IMVUTWATWN_LOP <br /> FACILm ID/ INea Accouw lO PRNIHJa I r '` i } ✓' <br /> 'iii .'�`'I 4�:? x t % I. ,;�. I . <br /> FACMJiY FILE COMPLETE TNEFOLLOWINO BUSINESS I FACILITY I SITE INFORIItin011l: <br /> Is this a NEW Business LOCATION not previctimly regulated by Bre EwHDNEEA rAL HEALTH DEPARTMENT? TEs ❑ ND,ET <br /> Is this an EXISTING Bueinese LOCATION but rayNEW <br /> W,TVIE:rat regulated <br /> Bualnese? ,,/ p � r� Yo ❑\ (NO Jr' <br /> Butim"efFAglmldITe NAYE(Z� t""'U KW K7 �t �RO a�. vow i -`^ <br /> SITE AQDREa9 �vp, ��d, O S� Suaes BwINPAe Pmoste i <br /> Cm �� V STATE ZIP <br /> CR R 520!�- <br /> eGAaDasurEewealr laacaaE / Mort IfeY2 <br /> Melling Adrlreea fDfFFZREArrf nFxfflfyAddIEsa Attention:orCare Of(opNwWl t <br /> �a���i� oq. e ¢1� c 1� <br /> IWMng Addmos l`�1 `E/� �I - <br /> P 'J�f \ G-S r�_., y �O� STATE LP <br /> BNJ DGDE APN/w`! ^—23 CtRa®¢: <br /> Tmw PAwy NkLUN6 b4M _Completed BillingPartyis ditrontlrom Property Owner orF&clllty Operator/denbftolabove. <br /> BWINeu NAME �C Attention:or Care Of( eorn�a1) <br /> Mailing Address o '\ t�PHK)14E <br /> Cm Are LP Ckff , &M <br /> see <br /> AMMIZaMM for toga and charges OWNER FACKmiBUSBIESS THIRD PARTY BIWNG <br /> mL.inn ..n CnAn u..r+.Arog+nw:ren•�...� 1.Um underYpmd ApperaOL¢rtlN eut 1 am ae Ower,Oprrinw,¢duthwtred Aame of ah Brhf.g,end g<tlt dl PaAmYFeaI <br /> Pen..ne,6mroawmvr 6.Aoas Aodl¢NpuA[rOA.ru uwrlW d M1ktlJt apentloo refit DebekA to me.t ek rddrn.H.etleed.bm r the d[YoonrAnaee[r far I tl�b file Yw¢Nfy,W t III]] <br /> Inr.matlon proWded w this upplicad.n true rad¢¢¢t;And deme m ngdoted oetlNtl.vvlll be pMormeA le eamNae¢xeb W aPPIl.W SAN JOAQUm Cos m Ofdinan¢Cod.alul/or <br /> Stand .tl SfATE nod!¢p'[D[RAL Luwa A,W Rawatlom. N dK aWenlglud ox.r,epmror,or agent of Hm Pnperly touted At Ibe Akve fAcNryAlte atldr.f,l berebY avtlmd¢tk fateafe A <br /> ny nIM aB r.Wh efd andromrcnW.f.rmeet id atlen r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT.goon.It Is avYhhN and et tlm time dmt It ii <br /> provided lame¢mY¢prten.tive. <br /> APPLICANT NAMEIPtEAIIE PRftar) �.? bz�r7 �'L-Q"2�ifCA�L�(�SIGNATURE <br /> TITLE TA%IDN peas a �`ZJ �n 3 -7/ b 10 <br /> Mie AnewnU gnu P.ov.Y cemp.e.de _ll_ t'— <br /> SITEMrtIGATIGN Aaouxr PAID DATE or PAYIENT pArrEln T'PE R!clvr/ CMlCKY REGewm Br Yisn"PLWFIO - <br /> FEE:4 '7 C)% <br />