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San quin County Environmental Healtllapartment <br /> DATE ' I (WASTER FILE RECORD INFORMATION "MFR'a GREENFORM <br /> / SITE MITIGATION&LOP <br /> SMADEDAREASFOREHDUSf QNLY DNNERIW tGCASEN�CD` 31 UNIT IV <br /> IWNERFILE:COMPLETF7HEFOLLOW/NGPROPERTY OWNER/NFORMAT/ON.' CHECKIFOWNER CURREMMYOMFILEWIMEHDEl <br /> PROPERTY OWNER NAME ( 1 <br /> First MI Last PHONE/NUMBER <br /> BUSINESSNAME E iL ADDRESS <br /> Owner Home Address <br /> CRy ""�� y� STATE Lv <br /> Owner Meiling Address QQr/ per– <br /> Mailing Address City �Y�L✓ !�/�' state�Y Y ZIP IQ�� <br /> CORPORATION El INDIVIDUAL❑ PARTNERSHIP El FED AGENCY El OTHER El <br /> SITE MITmAT1ON_ENVIRONMENTAL AsaC##M[NT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVEETIOATION_LOP <br /> FACILITY IDN INV$ ACCOUNTID PR NtROTY AeelgaeO EMPL r[e LEAD AOeNDY:EHO RWOCB DT$C_EPA_ <br /> 66 II D 06509 06g <br /> FACILITYFILE COMPLETE 7HEFOLLOW/NG BUSINESS/FACILITY/SITE/#FORMAT/ON: <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO <br /> BUSINess/FACILITY/$ITENAME /r <br /> SITEAODRESS SUITE# BUSINESS PHONE <br /> � �� /CG /C�Gc2Gf <br /> CITY $TATE <br /> � S � <br /> BOAROOFSUPERVISORDISTRICT LOCATION CODE KE" KEYt <br /> Meiling Address ffD/FFEREATbnrn FacNIyAddrtrss ABentlon:orCaro Of(opf/aWM// <br /> 33 ectc�i a e Serra e7� /V 3a b <br /> Mailing Address City ��/ / �STyiE ZIP a3y - �a <br /> r c� TGti i/yI <br /> SIC CODE APN$ m& COMMENT: <br /> THIRD PARTY BILLING INFO: Complete it Billing Party isdiKerentlrom Property Owner or Facility Operator idenb'Aedabove. <br /> BUSINESSNAMf WCOGre.Of(/OpOEna/ <br /> McIIIrp Address <br /> Iles 711-,ve,,17, <br /> l <br /> 74E. <br /> CITY <br /> CItt ��✓'a-,FPO /A/..S STATE zip <br /> ZIP <br /> AccouATAaa— for fees and charges OWNER FACILJTYIBOSINESS THIRD PARTY BILLING <br /> Ba G. D COMPLIANCE ACKNOWLEDGMENT: I,We mdmigued Appliran[,rertify that l em the Owner,Opomar,or Authorized Agent of Nis Busineu,vnd t aclmawledge that o0 PRRMIr E1=ES, <br /> PErvAL=,Ewt'oRcEnfFMCR.IRGsr and/or ArOMY CRARGEY aasociamd wish this aperation wig W belied m drnr identified above n the AccouMARDRISS for this rite. I also nrtiy that <br /> all information provided an this appbe.fi.u true and correct,and that W regulated activities well be harmed iv vcc dance with W apphcabie SAN JOAOLTN COUNTY Ordinance Codes and/or <br /> Smadardt and STATE md/or bSnFYat Laws and Regulations. As We undemigoed owner,operator,or 4 t of the property trd at the above fvcuiryhih address,I hereby auMarhe the rdeue at <br /> Any sad vU rauib avd ensiranmmmi u,..mt information m SAN JOAQOLN COUNTY ENVIRO NTAL HEALT7I EPARTNMENT as soon w it u av"ble and at the same time it u <br /> provided m me or my represenmave. \� <br /> APPLICANT NAME(PLEASEPRINT) �e//��S ��s "GtiniflaE--� <br /> 11tE .Sly TAX ID# g– ps�� <br /> A,PproYed By Gem 6/ 11Accounurp Ofrme Pracesaitq Complemd By Oe J <br /> SITE MITIGAT ON AMOUNT PAID DATE OF PAYMENT PAYMENT TYP RECEIPT# CHECK# RECEIVED BY WDRKPUNPE <br /> FEE:>< / 7-29- t� X810 29Go <br /> pit ;o1 <br />