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SanJ aquin County Environmental Healih Re artment <br /> if a GREEN FORM <br /> DATE ca 3 I ASTER FILE RECORD INFORMATION MFR SITE MITIGATION& LOP <br /> ammamw Top H12YKQnx ,D# CASE. SR(X)&8o 9q UNIT IV <br /> OWNER FILE:COMPLETE THE PROPERTY OWNERINFORM77ON.' CiimrwOWNER CURRENnrONraUwy"EHDE <br /> PRoremYONMrn NAME KFtf A. GAvT (to ) 4 —ybo <br /> N,E Mf Last PHO NUMEER <br /> EMNLADDnM <br /> "Neal NAME r I = FOf 1'41 FIn .C <br /> O ..l <br /> Owner Nolns Address TV� Q <br /> cny sTA LP q S Z0b <br /> S toc.K o <br /> ownermiduv Address O fxxlcr 9A. <br /> ltwa� 5 toGK T 4� 23P GSa? O <br /> COflI'ORATICN� <br /> 111 PARtNER9NIP❑ FmA3FRCY❑ ominto <br /> SITE MITIGATION_ENVgp090rrAl —VOWINTARY CLEANUP_WATER QUALrry HW PIPELINE INVESTIGATION—LOP <br /> FACNnYIDS INV/ ID PRH Oe AeSIGNEoE pLOYEE LEAo AGENCY:EHD�RWQCB_DTSC_FPA_ <br /> FACILITY FILE COMPLEM7rfE/SIULL BUSINESS/FAC ILITYISITE INFORMA770N. <br /> Is thisa NEw Business LOOAnaNrm4 regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YEs ❑ No� <br /> Is this an EXISTING Buslrfes►AOA7Mblda TYPE of regulated Business? Yes ❑ No <br /> BUewE891FACenvISC E NNE o '� /7 a <br /> SUrtE11 &191NE9e PHONE <br /> SIVE / �� •K a- <br /> 14 STATE LP <br /> CITY S 957-06 <br /> BDMaOF SUPExvoaR DlaiRICT G I T><HKI CGDe � I <br /> KEv1 KD2 <br /> Attention:OtCaTe Of(00W"9 <br /> Mailing Address AndWAtIA Not <br /> STATE AP <br /> Melling Address CRY <br /> SIC CooE �ME1111. <br /> THIRD PARTY BILLING Ilea Colr}MsPa BIIIing Party is diAerentfrom property r orFaeliity Operator idelyUfledabove. <br /> Owner+t- 4 AUanBan:cwOare Of(000MV <br /> Buswm MANE ALANC10 k, FAV f 'w1 1 <br /> MeiMBAddress S3 n O PHONE ZL�c XtI76 7/D�j b <br /> CITY Tv.� /4 CSrb� X 9 5 Z/ 5 <br /> �CcrostvtrAOOREte for fees end OlferEw <br /> OWNER FACILITYIBUSiNESS THIRD PARTY BILLING <br /> ed A Bnvt,ttrtlry that f am the Owner,Operator,or Authorized Agent of this Bottom and I aclmowledge that all PFReRTF'FGS <br /> B LLwiG AN11 CCMPI.IANLR ACRNOwIlaGMMeT: L lsa pp <br /> pEyttrrrs,B++'oRcoMENfOUAer1 and/or Nope Y aModated wIth Ihb opmdov will be blued to me at the addren Identified above m theACY Aponzgy for Uda site. f ago certify at <br /> au Lot.. .H..POvidcd ov thio aPp,,adoe b be and h,and that all regvhkd acdvitim will be tot of the Iroa¢o.d..led at the abov.ffalrituyla e a drew,I hereby•vthmiu the Neave of <br /> Stendard3 and STA'ra and/or FEDERAL I and m <br /> As the dmigned owner,operator, g P P" <br /> any and all reWb and environmental aa+rs<mat la tion to SAN JOAQUIN COUNTY E.NVIRONWNTAL HEALTH DEPARTMENT m 3000 m it h available and at the same Bme it b <br /> provided to me or my nprexvtative < <br /> APPLICANT NAME(PLEASE Plaw) M C E SIGNATURE A/krk�l <br /> TAx ID# <br /> TITLE L i M N/dI Cr1:A. 7 <br /> 0a <br /> bo Omca Naa«.hw canolabd Sy Data �✓ <br /> SITE MITIGA AMOUNT PND DATE PAYMENT PAYMENT TYPE RECEIPT/ CHECK# RECEIVED BY We P1Afl2PE <br /> FEE:III <br /> JJl tl' <br />