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r <br /> San Joaquin County Environmental Health Department <br /> DATE `� `� MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> o`-1 / SITE rfM'ITII'GATION&ILOP <br /> SNAOED AneAs ron EHO unr ONLY OWNER ID# CASES UNIT I'Y <br /> S90664(4 2. <br /> OWNER F1LE:COMPLETE THE FOLLOWIAIG PROPERTY OWNER INFORMA 77oN. CHEcx iF OWNER CURRENrc YON FILE wlrH EHD <br /> PROPERTY OWNER NAME <br /> Firs( M1 Lasl PHONE NUMBER <br /> BUSINESS NAME Tt`cf� ';q-e Sgle.s Toe� `-,tel <br /> �r�� �G C' ILADORESS <br /> Owner Home Address 6� T-62 <br /> {-}}z <br /> City STATE zIP 111 3 <br /> "7 <br /> Owner Mailing Address `� I� rU �-.�r � (� <br /> Mailing Address City �� Slat° zip <br /> ( t`4 45 3 <br /> CORPORATION ANDS W DUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSZCSSINENT_VOLUNTARY CLEANUP_WATER QUALITY�.HW PI111lL1NL'INVESTIGATION-LAP <br /> FActLITYIDI! INV# ACCOUNTID PR# OIl ASSIGNaDEMPLOYEE I LEAD AaeNCY:EHD—X--RWQCB_DTSC_EPA <br /> _ <br /> 11.(.X--1- G"l 1 !42 <br /> FACILITY FILE ComPLETETHEFOLLowiw BUSINESS I FACILITY I SITE INFORMATION: <br /> is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO <br /> BUSINESSIFACILITYISITE NAME 5 IIA <br /> SUkTE# BUS{NCSs PHONE <br /> CITY _ TY". STA ZIP <br /> T(,c4 c- CA- <br /> BOARD OFSUPIRVISOR DIM= 6� LOCATIONCODE �3 K�'� KEYZ <br /> 1 V <br /> I <br /> Mailing Address IfOIFF€RENrfromFacffifyAddresa Attention:orCare OF(aptlonalJ <br /> Melling Address City STATE ZlP <br /> I SIC CODEff <br /> F <br /> OMMENT: <br /> THIRD PARTY BELLING INFO: Complete if Billing Party is different from Property Owner orFacility Operator identified above. <br /> BUSINESSNAME Attention:orCarOOf (opl/ona1J <br /> t./t'rcovol <br /> Mailing Address PH N w i <br /> CITY 5T ZIP <br /> ACCt]1II 6QDBESB for fees and charges OWNER FACIL"IBUSINESS THIRD PARTY BILLING <br /> RILLING AND COMPLIANCE ACKNONVLEUCMENT: I,Ille undercigncd Apphcanl,certify that I nm the Onvler,Operafor,Or Afilho ized Agefar Of this nosiness,and I aclwaxledge that all PERMIT Ftilis, <br /> Prrv.+Lrres,E,vrUaCNnm:\'TC'H.IRCBs and/or HoL+RLI'C1rdR6E'S assOciafed With thls Operation will be billed to nic al Ilse address hl entitled above as ilii f(-rnihVT,fnnuras Far thlfs site. 1:d5O rtrtify Thal <br /> all inlbnnalion preritlnl On this applieOliOII is true null cnrrecr and that all reguhated activities trill be performed In necordance with all applicable SAN JOAQUIN COUATs'Ordinance Codes nndiOr <br /> StandardS and ST,%TE andiar FEDERAL Lasys and lieguhatiois. AS Ibe undersigned Osrner,opei ntor,Or agent Ofthe property located st the above rncilityisite address,l hereby authorize the release or <br /> any and nth results and en4'1rnlHtleldal assecsmrot infnrn:atiou IO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTA[ENT as soon as it is arnilable and at the same line it is <br /> prmided to nie or illy represctliative. <br /> APPLICANT NAME(PLEASE PIUNT) Q To <br /> TITLE � SIGNATURE <br /> n TAX ID 0 <br /> t'FG <br /> Approved By 11 out. Accounting Omen Proco.sIng Completed l3 _ D©19 �! <br /> SITE MITIGA'r1ONFAmOU74TPA it) =PATIEYMENT PAYMENT TYPE RECEIPTS CHECK 0 RECEIVL•D BY WORK PLAN PE <br /> ! <br /> FEE: � G <br /> ` <br />