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Sari Jc, jin County Environmental Health Dep; ent <br /> DATE y/y MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> S1TE MITIGATION & LOP <br /> SHADED AAEA6 rOq IJ EHU USE ONLY WNER IDg CASEN UNIT 11/ <br /> OWNER FILE:COMPLETE 7HIEFOLLOWING PROPERTY OWNER INFORMA77ON: CHFCKIF OWNER CURREN71YONFILCKM EHD <br /> PROPERTY OWNER Nme r • e <br /> o!i� G' ' c., t (Yoe) `�Y - �`�l �C!, <br /> Fist Al! Last PHONENumsm <br /> BUSINESS NAME L --- E-"LADORESS APR Jf) <br /> Owner Home Address <br /> - l=NVIR e,NlA±1n _ <br /> city STATE zIP PEl,MI%/SLfVf �LTri <br /> Owner Malling Address OO <br /> MallIng Address City Zip ! <br /> C.ORPORATIONA INomouAL❑ PARTNERSHIP[j FEDADENCI'❑ l0-niER❑ <br /> _ itvEmt;AnoN_LOP— <br /> -- <br /> FACIUTYIDt IHval ACCOVNTID PR#IRO1 AsslnNcoEw c LEAL)AceNcrEHD <br /> $rrE maAnDN_ENVIRONMF?(i/LL ASSESShEEN'T VOLUNTARY C.t>E�anl1P—WATER QUALJiT_HW PIPELINE I , <br /> OCFI TSC EPA_ <br /> l5 z 2 SSS ab$ - <br /> '� C"CO <br /> FACILITY FILE COMPLETEruffFOLLOWWING BUSINESSI FACILITY SITE INFORMA770N.' <br /> Is this a NFW Business LOCATION not preylously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YrS ❑ No ❑ <br /> Is this an EwsnNG Business Lorwm but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BuswcssTA=m1SrTE��'NAME o r / <br /> SnrEAODREss ¢ SUITE# BUSINESS PHONE '�_o z4tK— �.A <br /> f <br /> Cm 3 zip <br /> � 3 <br /> tJoaaoDFBupQtvisoRD LOCAT.11G 1i- KEYS KEY2i:. <br /> Mailing Address MMERFVrfro n feopltyAddrera Attention;arCs re Of(cpf"I) — <br /> �� <br /> Melling Address City <br /> SIC COO E APN/ ���J t� 2 d .Co►+»ttr. __ __ --__ <br /> THIRD PARTY Biwmc;INFO: Complete if Billing Party is different from Property Owner orFaciilty Operator idenUfled above. <br /> $UStNESSNAME AttenlluLT:tarCare Of(opXorre/J r <br /> oil <br /> MallIngAddress / /O/ PHONEO?� _ 0 <br /> Cm ll/ Q _. —. STA q 5 <br /> AgPq N1Aa W3 for foes and charges OWNER FACILJTY/BUSINESS THIRD PARTY BILLING <br /> BrLLU;c m-p Cu,mpL t&)ice Acia O".LDGmENT: I,the undersigocd ApplIcaut,certify tbat i am the Ohne,Operator,crAuthorized Agent of Ibis Business,and I aclmowledget <br /> lut all PU urrF?rs, <br /> PE,yamy,Et mxcxyE tO ARM and/or Romy OuRGL s Lismiota with this operation will be bt7ldt tome at the address Identified above u the ACCocwrAnnAtzs for this site.I also certify tbat <br /> all Lnfornution provided on this application is true and urrrect;and that all regulated actisiuty will be perforcoed in accordance with all applicable SAN JOAQuvi CoLV"Ordiosace Codes and/or <br /> Standards and STATE aad/or FI:DzRAL Laws and Regulations.As the undueigned owner,operator,or atent of the prop"located at the above facility/aite address,I hereby authorize the release of <br /> say and all results mad environmental assessment information to SAN JOAQUIN COUA'TY ENVIRON.N=AL REALM DIZPART?IYINT as soon as It Is available sod at the same time it is <br /> provided to me or my representative. <br /> U <br /> APPLICANT NAME(PLEASE PRjw) /�tC� SIGNATURE Q <br /> TITLE G/l�li7vl✓t'L2ysi�L`,� �, L i"��i,,4 rt TAx ID# <br /> Approved By Date Aceou Office ProcesAng Completed By U lO O( Date <br /> SRF,MmGAINON AMOutn'.PAID DATE OF PAYMENT PAYstENTTYPE RECEIPT i< CHECK II RECETV[:D$Y YVORKP}IA .P:E� } ' <br /> FEc:§ „ r ? <br />