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• Y <br /> _ San Jc ,.lin County Environmental Health Depi.._,tent <br /> DATE JC�//� MASTER FILE RECORD INFORMATION `MFR" GREENFORM <br /> / SITE MITIGATION& LOP <br /> $IMLP➢•RLA3rOREHD USC O� OWNER(DN CASEX. UNIT IV <br /> OWNER FILE:COMPLETETHEFOLLOWINGPROPERTY OWNER INFORMATION; CHEcxtfOWNER CvRRrNnyoNnLrwmtEHD <br /> PROPERTY OWNER NAME TIS.. /\ C� <br /> First M!Y M! Last PHONENuusER `J <br /> BUSINESSNAME C,l EAtWt — <br /> 1lll .m <br /> Z <br /> Owner Horne Addre," J <br /> city — STATE <br /> 11— <br /> Owner MaUlnp Address fes✓ 4 CwiF�[(,i s:' n,�,l <br /> t 1 <br /> P z <br /> MDlllnp Address City UState Zjp , - .'>::a —7 0 <br /> CORPORATION❑ NDIVIDUAL❑ PARTNt:RSHIPEl FEDAGENcyE1 OTH <br /> _ SITE MITIGATION aoNMENTAL As8E88M OLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> FACiurY ID k3 Irrvll ACCOUt1T ID PR MAIC A33IGNED ELPLOY E CeAD AGENCY EHD " RWQCB T9C EPA ralt� <br /> FACILITYFILE COMPLETE TNEFOLLowmaBUSINESS/FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not preylously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an Ex STING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No ❑ <br /> BUSIN[SSIFACIIJT•fISfTENRME 1 � <br /> $�ADQRFS9 �•J SURES 8U MESS PNOtlE <br /> �i her 7- v�- C fit,. 4- 5� <br /> CrrY SrZIP <br /> ra S 7 <br /> DOAROOFSUPERVISORDI ICT LOCATH)NCODE KEri KEY1 <br /> Malling Address 1fD/FFERENTfrnmFaG/1tyAddrvss Attention:orCare Of(opUoneq -- <br /> Matling Address City S L <br /> SIC Cone' APN M C <br /> THIRD PARTY BILLING INFO: Comple a if Billing Party is different from Property Owner orFacility Operator identifiedabove. <br /> BUSINESS NAME I Attention:arCare Of(cpdoml) <br /> pro YYl Lee <br /> MellingAddroas61DI PHONE ?W5.790-1'� Y 17 <br /> Cr" <br /> STATE LP <br /> v+� G4- 3 <br /> AnQxNATADDaM forfoes and charges OWNER FACILITY/BUSINESS THIRD PARTY B1WNG <br /> Bu-j1NG AND COhrPIJA.NCE ACKNoNyLFDGMEhT: L the undersigned Applicant,certify that I am the Owner,Operator,or Aurhori,ed Agent of this Business,and I acknowledge that all PrKwTFL&S, <br /> PLNAf.W,F.NFDxd.,eravTClLaxt23'anNnr AAOURLYCHARCFS associated with this operation will be billed to me at the addmt Identifltd above as the AcrnrrhTAnnArzV for this site I also certify That <br /> all inrarmati,m pro,ided nn thil at piicallilll Is true and correct;and tbat all regul-.ted actisi6es wPl be pelf—"l lu accordant WUL all appflcablt SAN JO.AQULY COUNlY OnLnance Codes aodtor <br /> Standards and Srsic and/or FYu)ERAt,I.%s and Regulations.As the uerty aders(ped owner,operator,or agent of the proplocated at the above facility/site address,I hereby authorize the release of <br /> any and all muWo and environmastAl asscssmcot Information to SAN JOAQUIN COUNTY ENVIRONNW—WAL HEAIAT1 DEPAR"1 as soon as it is available and at the same time It is <br /> provided to me or my represeatAtiv <br /> APPLICANT NAME(PLEASEPRINT) Lr, f- Ac-) SIGNATURE' / <br /> TITLET <br /> p J 4019 <br /> #l0 <br /> Approved By Date Aeeaurding Office Procasaletj Completed Dy Date <br /> SITEMIT1GAnoN' AMOUNTPAID DATEOFPAYMENT PAYMEwTYPE RECEIPT# CHECNpRECEIVED BY -i"WoRt(PfaNPE <br /> FEF:¢ - <br />