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1 0 <br /> SAN JOAQUIN C�UNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE 1 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION& LOP <br /> AMM FOR EHD USI Old OW NER 1113# CASE$ I UNIT V <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESpbNSIBLE PARTY INFORMATION: CN6cx/PON9VEvacuon--wavON.-ILEWTH EHQ (� <br /> PROPERTY OWNER NAl G �� I 5 01 G �, ��� ' <br /> h 13 '` 111 r"� <br /> FAST Ari LAST PHONE Nuump <br /> BUSINESS NAME a4buL ADoRESn <br /> OWNER Hour AoDREsa <br /> c" STAM <br /> OWNER l"UNG ADORESB <br /> MAIUtio ADDtteaa Orry STATE ZJP <br /> I <br /> F-❑CORPORATION ❑iNONIOUAL 0 PARTNERSHIP ❑GovERN/ENTAugNpY RGaromului a PARTY O OTMM <br /> ESTE MITIGATION_ENVIRONMENTAL ASSESSMENTVOUNTARY CLEANUP—WATER QUALITY_HW PIPELINE INVESTIOATiON__LOP <br /> FAckrrY lO ti <br /> It" AccouNT.10 0,1111 R011 Atie)W o l=taPt v�ti LEAo X CY:EHO_r R1NQC9�dT8G EPA <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJE,�T INFORMATION: <br /> IS THIS ANEW PROJECT LOCATION M PREVIOUSLY REGULATEDII Y THE ENVIRONE <br /> MENTAL HEAml DPARTMENT? Yes No:, <br /> IS THIS AN EXISTING PROJECT LOCATION,Bur A NEW SCOPE OF WORK? YEs No Q <br /> BUSINEaWFACiuTY/SnWPROJECr NAME 1.J z, <br /> 4 Srrr.AmmEas I PRruccT LIJCAnom Surm0 BUa1NEaa PHONE i <br /> ctTY STATE ztP <br /> BOARD OP SIiMWiSOR 01w,00 - LOCATION CODE '1 Keel K9Y2 - <br /> IiMAtuNO ADDRESS,w ownftew FROM FAtattrt AoDITEse N ArnwriON'OaCAwE OF(OIv770N4Lf <br /> i <br /> MAw"ADOResa Cllr I STATE ZtP <br /> Stc Com 7APN i u OoNMENt <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PAR ry IS ownRENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> ElOWISY NAM& ATTENTION:ORCAREOF(ONTA7,Vaef <br /> f"UNG A00AE" PHONE <br /> CttY I STATE 21F <br /> ACCOUNTGG <br /> AGGRESS To SEND FEES AND CHARGES: "ERO FAcjLrrY/BU81NES80 THIRD PARTY BILLING[] <br /> >•:I��i�I 1 ill ISI 111� fit•I 11I I I�i�I ���II R I�� �i�Pii� IIIc 11 I <br /> It51LL'36A.�U CA.\frtukt AC. OWte]>CniltNi: I�the una>ea�ed App3:c�,coat fy&at I am the Owner,Opevulos.AoGwraed.tmL or Ratpokdble Puny and I tclowwkdte thnt on P&M r];X0, <br /> PEV4LTIS\.EJV"6AlKN7 0(AMMV.-Ld r lfoeter:r OURGss Aacnetated with t`tea project win be 68ied to me at dw addrea idenfirwd abtw-e m the AccoO,\TAVUU Ss tar iMv alta I also certify thAt all <br /> informaGan pravided nn&6 appliGltietl u true and correm.and that ail regulated acthitke will be pwrarmed in accordance with all applicable W4 JOAQLvi COutttY QIRDL+UNQ CODES and/or <br /> S TA�t Acts noel SrATa and/or biBRAL LwAs anA YZLCLY AT[O.wS As the avdet�igaed O raver Opp A rd�ariLrd Aprt t,or Raz oev3btc Pm y for for project IarAfrd Ah.�'c aosler fael:ry/�ilr ad.Irem;1 <br /> brroDv anthotize me rvIcAte of M and all mulm tcp m and other emiroD.catal nscjx cmc mdortaafwn to SAN JOAQtWi COM-rY E.Nv'otONN(1�SEWAALL HEALTH DEPA <br /> R <br /> TMENT as cool:M it Is av*Babk <br /> and at dlc AAmc time it 4 provided to me m afi rcp.•nattadaY. �a'L�. <br /> APPUCANT NAME(PLEASE PRINT) SiONATUR� � <br /> TrttE TAx10S <br /> APPItoveo BY DATE LA xmNTme OFncE RtoM&*NA COIIPLETM RY OATE <br /> Fee:$TIQ/ITION Alrou►tr PAr DATE Of PAYMENT PA/aiENi IYYE RECEIFr g CNECK fi RECEIVED BY *6w'P'LA7.N PE <br /> TO 39dd 1N3�li NViS 60SZL5660Z605ZL5660Z ZS :60 6TOZ/bZ/90 <br />