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San Joaquin County Environmental Health Department <br /> DATE y MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADED AREAS FOR EHO USE ONLY OWNERID# CASE# UNIT IV <br /> OWNER FILE:COMPL=THEFOLLOWINGPROPERTY OWNERINFOR,RATION.• CxaexeFOWNER CuRREM7LyomnLEwwEHD <br /> PROPEKTI'OWN--:R NAME <br /> Frt <tt Last PHONENumem QED <br /> BUSINESS NAM£ Pac <br /> E-WIL ADDRESS <br /> AFR 011 <br /> Owner Horne Address <br /> 1=rav1R r. •_ter <br /> cite STATE zip PEG 'ijY�c+- EA�rI f <br /> V! <br /> Owner Mailing Address O 0 <br /> Melling Address City,( ZIP <br /> CORPDRATI-/ INDImcluAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER El <br /> SITE MITIGATION_�EIMRON1t u "AL AwEssMENT VOLUKTART CLEANUP WATER QUALITY_HW PIPELINE INYEsnaAT1oN_LOP <br /> FAciuTY160 iNV2 ACCUUNTID PRN/Fit A63IDNFliEalPti0 LEADAGENcrEHO B T3C ' EPII� <br /> FACILITY FILE COMPLETE77IEFOLLowINGBUSINESS/FACILITY/SITEINFORMA77oAf.' <br /> Is this a NEW Business LOCATION notprevlously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes ❑ No ❑ <br /> Is this an EASTTNO Business LOCATION but a NEW TYPE of regulated Business? YEs ❑ No ❑ <br /> BUsUNsSIFAmmtISITENAME L A <br /> 0• <br /> SITE ADDRESS Sur EK BUSINESSPHONE / <br /> CITv LP <br /> Fro- 3 71 <br /> BOARD OF SUPERVISOR D .LOCATION CODE- - KEY1 KEY2. <br /> Mailing Address HD1FFERSVrfrrm ra,-0yAdchaaa Attention:or Care Of(optional) <br /> 106 Z. 34 il <br /> Malling Address City z 3 &-Vzp <br /> SICCOCEAPNtZ�S IS�62. <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator idenGFed above. <br /> BUSNESS NAME , n Attenflom orCare Of(apbbov ; <br /> Melling Address Cly/O l PHONE V_5 - O <br /> ' i�7 <br /> Cm Q ^ STATE <br /> AprouATAaagm for fees and charges OWNER FACILrrI'IBUSINESS THIRD PARTY BILLING <br /> Bru.Wc,"'p CompLtkNcF Ac)QgOw izDr ENT: L the underslgecd Appilaut,ardfy that I am the Owner,Operwor,crAuthorked AgrAt of this Busium,and I admowledge that all PER.+orF�rs, <br /> Prx cLms,Esm)ra n�.m'CAaG s and/or HouxLyOuRu s assoelsted wllh this operation will be belled to sae at the address identified above as the e4nm(WrAnnitsss for this site I also cera fy that <br /> all information provided oo this applintioa is true and ourrert;and that all regulated attiNitia will be performed in accordance with all applicabie SAN JOAQuDq CoLwry Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations.As the undersigned owner,operator,or agent of the property]Dated at the above facilitylute address,I hereby aathnriza the release of <br /> RAY and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONSfENTAL HEALTH DEPARTIvi Nf as soon as it Is avaslable and at the same time It is <br /> provided to me or my representative, r <br /> J U �. <br /> APPLICANT NAME(PLFASEIsHm) *. ISIGNATURE <br /> TITLE G.�,~✓r�-�,��(<..� ,�, �61P TAX I D# <br /> Approved By Date Access ng Office Procesalrrp Completed By Date <br /> SrMMMGAT10N AMOutn&PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORK PLA[t PE <br /> .i s <br /> FEE:$ - , <br />