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San J&uin County Environmental Healtl#partment <br /> DATE MASTER FILE RECORD INFORMATION " " GREEN FORM <br /> MFR <br /> SITE MITIGATION & LOP <br /> SHADEDAREASFONEHDUSEONLY OWNER IDN CASE# UNIT IV <br /> /YYNERFILE:CAMPLETE7NEFOLLOW/NGPROPERTY OWNER lhoron 7mN. CHIcKfrOWNER CusnENrzyoNrcemniEHDEl <br /> PROPERTY OWNER NAME , <br /> Final Mi Lest PHONE NUMBER <br /> BUSINESS NAME EMAILADDRESS <br /> �/ / C'orrso/da.�iof .L. ✓Y <br /> OMRIer Harre Address <br /> City STATE ZIP <br /> Owner Mailing Address <br /> Melling Address City /Y,d. ' Zip /41 <br /> CORPORATION❑ INDIWDUAL❑ PARTNERSHIP❑ FED AGENCY orXER❑ <br /> BITE MMCkATION_IINWRONMENTAL ANNEseMENTx—VOLUNTARY CLEANUP WATER GUALRY_HW PIPELINE INV EeT TION_LOP <br /> FACIUTYID INV# AccOUNTID PR 111x# ASSIGNED EMPL YEE LEAD AoENCY:EHD WQC TSC_EPA_ <br /> 06 D 8 <br /> FACILITYFILE COMPLETE 7NEFOLLowiNG BUSINESS/FACILITY/SITE/NFORMAT/ON: dftw <br /> �,( <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES El No ld <br /> IS this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO <br /> BUSINESSIFACILmISRENAME /r�rb f-o -- ,LTG` �G �"��" • <br /> U" �r <br /> ( SRE ADDRESS v SUITE# BUSINESSPHONE <br /> S est �� Go /L dceG� <br /> CITY STATE <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYt KEY2 <br /> Melling Address MDIFFERENTbwn FwcA`WAddress Attentlem:arCare Of(opgbrasi) O <br /> ✓VIE 3d b <br /> Melling Address City <br /> SIC CODE APNN COMMENT: <br /> THIRD PARTY BILLING INFO: Complete/f Billing Party/s different from Property Owner orpFBDancility Operator ident/Aedabove. ` <br /> BUSINESSNMIE /1OF U'''/l le'I`F"D/! .f�l.!/7� / „�'4dl <br /> �Mof(optlany <br /> Melling Addns/sttt .� 7✓Es r!c,r7� f�`~ _ [t.'�G. Z�Y Pmlee✓/� ^-` j.��� <br /> CITY /v `� STATE LP s � ,y <br /> e.v»tt_.AnoRFee for fees and Charges OWNER FACILITY)BUSINESS THIRD PARTY BILLING S—•. <br /> BILLING AND CO,WI IANCE ACKNOw EDGmENT: 1,the uedersiened Applicant,certify that 1 am the Owner,Operator,or Abhorred Agent of tltis Bluineq,and 1 ac4eowldge that ag PF.Rn1R F2'EY, <br /> PEI✓AL1 ,ENFoRcE yCivnitCEs And/or 110 E YCHARGES aaociated with this operation will be billed to me at Meaddrerr identified above ae the ACcol/MADDRF_ss for this rites I abs certify that <br /> all information provided on Win application b true and correct and that all regulated activitica will be performed in accordance with all applicable SAN 7OAcy m COUNTY Ordinance Codes and/or <br /> S=lot,,And STATE And/or F'EDDe Law,And Repdatiom. Aa We adeni�ed owven aperntor,or agAnt of the property' ted at the above facilityhite address,I hereby autharbe We release of <br /> Any and all raulb And a viroDmental assessment information m SAN JOAQUIN COUNTY ENVIRON11t6NfAL BERETS EPAAT'MENT u noon as it is available and at We same time it is <br /> provided to me or my rcpreentafiY- <br /> APPLICANTNAME(PLEASEPRINT) �e////rs �A,ee.S SIOIW / <br /> _1 <br /> /TLE TAX ID N <br /> �Q <br /> Apro ad Oab _ Accounting Office Proceaing COmp;eWd By M <br /> SITEf111TIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# ONErQY�K9 RE IIVEDBY WORK PLAN PE <br /> FEE: L�I arZy.11 VY/ I r l�� <br />