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0 • <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADED AREAE FOR EHD UEE ONLY OWNER IDA CASE! UNIT IV <br /> OWNER FILE.COMPLETE PROPERTY OWNER!RESPONSIBLE PARTY INFORMATION: CHE/CK1FOwnerF1$CURRen7t.YOH17Lerrmr EHD <br /> PROPERTYOWNER NAME \ `q q j-720 <br /> Ftgsr M1 LAsr PHONENumeER <br /> BEMAIL ADDRESS <br /> USINESS NAME <br /> Ll{ 'x C.a-tti« <br /> OWNER HOME ADDRESS Z10 o U,,,A� e�.O — - [ <br /> 1/. T` b r, <br /> CITY �7A ztP (J J Q <br /> OWNER MAIUNo ADDRESS f` y� <br /> STATE LP <br /> MAR1Na ADDRESS CRY <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP GOVERNMENTADENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITC MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELIN!INVESTIGATION_LOP <br /> FACILITY INvI ADcauNrlD PRiIlROt AEetoNmErrLOYEs LEADADENCY:EHD�ftWQCH_DT3C_EPA <br /> FACILITY FILE:COMPLETE BUSINESS 1 SITE/PROJECT INFORMATION: <br /> ISTHIS ANEW PROJECT LOCATION NOT PREVIOUSLY REGULATED SYTHE ENVIRONMENTAL HEALTH DEPARTMENT? YES,K NO ❑ <br /> IS THIS AN EKtSTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES ❑ NO <br /> BUSINESSTACIUTYISRE/PROJECTNAME S 0rM E0-0 <br /> SITE ADDRESS I PROJECT LOCATION /� SUITES8 SINESB PHONE <br /> / <br /> / 37 TE ZIP <br /> CITY .roV <br /> BOAROOFSUPERVVISORDISTRICT 3 LOCAMNCODE �� KEY) KEYZ <br /> MAIDNO ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:OROARE OF(OP7MMAL) <br /> Mmuw ADDRESS CITY STATE TJP <br /> rC CODE Al)•l,>K I- � �C' COMMENT: <br /> IU- <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESSNAME (_ 1\1�/^0 ATTENTIOWORCAREOF rOPM144Lf <br /> MAIUNa ADDRESS l-: `�\J`lU�l=�(�w /`_n U� /. �` " C2,5 <br /> 0 PHON 9 � .'J6G__ G�0 <br /> DRY San arn�n 11CTS vP '3 <br /> ACcouNTADDREssToSEND FEES AND CHARGEW. OWNER❑ FACILITYIBUSINESS❑ THIRD PARTY BILLING <br /> RILLINr AND C0NM.IANCF.ACKNnwIS.nCatr..NT: 1,the undersigned Applicant,certify that I am The Owner,Opermor.Amhnrr;ed.4gcn4 or Responsible Parte and I acknowledge that all PES.itIrFEeS <br /> PLv tL71FS,rNrcRCEtt&%-rCt1,tRCEs and/or IIODSL7 C1IARGET assoeinled with this project vvin be billed tome at the Rddtrss identified above as the ACCOInTADDHEST for this site.1 also certify that all <br /> inrormadon provided on this application Is true nod correct;and that all regulated activities Ivill be performed in accordance with dl applicable SAN JOAQUIN COIINry OnDIN&NCE CODES andlor <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS.As the undersigned Owner,Oprratrm Aathorisd Agcn4 or Respowlbk Piero,",project 1 4 attove under facilitylslic address,/ <br /> hereby oulboria the release ornay and all resells,reports,and other 74\ <br /> mcnled uscssmeat infarmotlon to SAN JOAQUIN COON"F. AL 1I ID P TIENT'a soon as it is ovaileble <br /> and at We same time It Is provided to sec or my representative. ,1t <br /> APPuCANT NAME(PLEASE PRINT) ISL CkQr, U1^! ,/ $IONATURE <br /> TITLE !� �VI'����'~` Sei���'�t TAKIDII <br /> ffFFE:$ <br /> veo BY 1.•• DATL ✓ ACCOUNTING OITICE PADCEaa1HOCOMPLUM13Y DATE <br /> ITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT!/ CHECKS RECEIVED BY WDKP E <br />