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r San Jo..lin County Environmental Health D,,,,Ertment <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> u'l I I SITE MITIGATION &LOP <br /> SHA A_RCA5 FOR EHO_4$ Q.NLY OWNER IDN CASE UNIT IV <br /> OWNER PILE:COMPLETETHEFOLLOW/NG PROPERTY OWNER INFORMATION.' CHEcxiF OWNER CuRREmayoArFxEw/rri EHD <br /> PROPERTY OWNER NAME ,e N MC (� VGt V' V"g <br /> First Mf Last PHONE NuMam <br /> BUSINESS NAME C-MAILADOREss <br /> Owner Home Address VC) <br /> C) 6&Y 5-04-4�/ <br /> r ¢j <br /> city S ot,r to L"i-•Cl/n STATE ZIP / Q <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> I <br /> CORPORATION❑ INOMDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HIW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INVN �co�u1' ��CRO#S A si NE fEMPLOYEE LEAD AGENCY:EHD�RWQCB_DTSC EPA <br /> FACILITY FILE COMPLETETHEFOLLOW(NG BUSINESS/FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO-S <br /> Is this an EmSTING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No Z� <br /> BusmEsslFAOluTY1SITE NAME <br /> SITE ADDRESS ! f e''�'-�7 1�1—c- <br /> ` CA v SURE# BUSINESS PHONE <br /> ` b l_ ZS-- O <br /> CITY s�VCJC- �-- cit- ZIP <br /> L!n.-- <br /> SUPERVISOR DISTRICT LOCA'nON CODE KEYT KEY2 <br /> Mailing Address lfd1FFEREATfrwnFecAWAddress Attention:or Care Of(oyolional) <br /> (VIOL em 5'37-( Sam kat,#A&rh -5-ke mi, r j(-rf,pw, <br /> Mailing Address City STATE zip <br /> SOI sn. t2.���-• JT <br /> SIC CODE APN# Z C' ` COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFacility Operator identifledabove. <br /> BUSINESS NAME Attention:orCare Of(op64anal) <br /> Mailing Address PHONE <br /> e)14. Z6—/'l Fq+-fit] <br /> CITY <br /> �o 1Co.v� CA- cj St: is <br /> ACCOUNrAlawfw for fees and charges OWNER FACILITYIBUSINESS IRD ARTY BILL/ <br /> RILLFNG AVr COMPLIAI'CF ACKNowt,fnC+IF1%7: 1.the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Rusiness,and 1 acknowledge that all&:Rmir FEES, <br /> PF.An1.RFS,EjvfbRf6AFE,ITCHARCFT andlor 1101IRLYCI1ARUtS associated with this operation will be billed to nit at the address identified above as the A(Y'UUVTAbbREcc for this site. 1 also certify that <br /> all information provided on this application is true and correct;and that nil regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and M ATF,and/or FFbF11tAl,I,aws and Rtgulalions. 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 ENVIRONMF:NTAI.iIFALTH 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 PRiNr) �b��l SIGNATURE <br /> TITLE �< TAx ID# s7+ 6 3-73 2Z <br /> � r <br /> Approved EX Date Accounting OfFlce Processing Completed By Date <br /> SITE Mrr1GATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT N CHECK N RECEI�p$Y WORK PLAN PE <br /> FEE:s3�,�, 03(�(,•cc� a fs/rl ✓ �3`�b�3 <.dC 3�`O <br /> 3 <br />