Laserfiche WebLink
0 0 <br /> San Joaquin County Environmental Health Department <br /> DATE { MASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> 27 UC 20 l l SITE MITIGATION&LOP <br /> SHADED ARE•e FDREHO UM ONLY Owmat IDG CAeER� 1)01.3 / 9Q UNIT IV <br /> OWNER FILLS:COMPLETE THEFOLLOW/NG PROPERTY OWNER/NFORMAT/ON: CAEc o,OWNER CUAZfiMtvavruEW?V EHDE1 <br /> PROPERrrormuNAMe 06fLi C T3A0D (60) 6u -2 ,062_ <br /> Firsl MI Law inwone'Nutesm <br /> Bulamaa NAME 76F�N PrGert St1WES reor vo6trfc �, •aha deeare.c.� <br /> ON Home Addrou <br /> city t� STATE LP <br /> Owrear Melling Addnes A �41(1V \IL f:RG v�A <br /> Mding Address City M10L1(✓1� etate z OP61us <br /> L <br /> CO Tl01I( INOmnuAL❑ PARmesoneP❑ FWAOENCY❑ OTHERLj <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOWMARY CLlANUF_WATER QUALITY_HW PIPELINE INV6ETOATION_LOP x <br /> leaarrTloN INV# A000torrID (PR*06# ASSIMEDEMPLOYEE Lr AGENCY:EHD_RWQCe DTRC_EPA_ <br /> Is's �7S(ov D ' 34L <br /> FACILITYFILE COMPLETETHEFOLLOMNG BUSINESS FACILITY/SITE tNFORMA770N.' <br /> Is this a NEW Business LoCAnON not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes ❑ No 5' <br /> Is this an Ex=NO Business LOCATION buts NEW TYPE ofregulated Business? YEs ❑ No <br /> ElusiNEWFAGIITee/Si ENAeE FD"rtX I-ESto FAmLIT'1 <br /> &TEAooaeu2 8 2 9 W �4AJri'1NhTi N STT-GGT Boned &IaINEBe PHONE <br /> A <br /> Cm STATE STaC�rry Pi C!4 ar 957 0( <br /> BOaRDOFStIPE1NlaOfl DMfaIOT LOfSTbNCODE KEY1 NW! <br /> Mallln0 Addrosa HOlFFERENrbornFaaftAdnyws Afteretlon:orCare Of rapu�.� <br /> JotW 7GER-E laL� ItD6ERT g�Q <br /> "Ing Addre.Chy MOLINF f2A 2V <br /> 6165 <br /> SIC CODE ITN CCNMENT: <br /> / THIRD PARTY BILLIN�GAIRNFOI Complete it BIIIing Party is diNerentfrom Property Owner orFacliRy Operator idenfiriaefaa^borve. <br /> .� BuwNeesNANe I: —WKT(SNC • Attention:o Care IN/kpkb,;W)Nit <br /> i Sc4ettllt& <br /> Mwlkv Addmu�./, 2�5♦•2A5E��N Aro A4A3 P4itic- �ILIN� SJ IT7=_ 3SA PMONE "/6-9'-z{Y-(737L`3 <br /> (\I c" JAca-e\I„Y'T� BTA?! 51.5 <br /> Ad^Ol/NrAOOREBs for fees and Charges OWNER FACILITY/BUSINESS CHIRD PARTY BILLING <br /> RiMINC AND CompuAKE ACKNGWLEDCAIEM: I,The undersigned AppiiCmI,eenify that 1 am the O,Hrtr Operator,or Aulhorked Agent of Ihb BASIDels,And I ula oWledge that all Push Feiss, <br /> PPNALTJEP,FNf01((&V&YT C'NARG$CpRdIO[HOURLY C"NARGPS wTOelAled W IID TLN OPPraaOn\Vi81.P blBed 10 me RI file RddrPSf IdladBef RINV!w Ih!All'OUNrAODRPSr for the 91a. l abo artily that <br /> AD infnmintbn p,.Med oD lhb Applkwl..b true Antl aortae?;and that NI regulated ReHvitks rvlll be perfornHd w ucordana W IIh a0 ApplitAWe SAN JOApaln Courcrc Ordlnana Caes md/or <br /> Suadaeds and STATE and/or FEDERAL Lam and Regulations.As the undersigned matt,operator or ngemof the property bated at the Above fecilitylske add rees,l ereby Aulhoda*"enI..f <br /> Any and RO M.fta and tavtronmenlw aMasment informalWn to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH �. leand.111N.A.4ratilleDEP <br /> provlded to me ormy repre,.I.fle. D <br /> APPLICANT NAME(PtPaee PRINT) RDty EO-T- Boot) SIGNATURE <br /> TITLE Rcftrga,W" MANkGC'R- TAx10# 36.443SSSu <br /> AP .d By oats Aooamun Omoa ProoaAelnaccrephrewlsy Data <br /> SITEMITIGATION AmouNcT,PNO DATE OF PAYMENT PAYMENT TYPE RECEIPTS CNE-0N4 RECEIVED BY WORK PLAN <br /> /PEy� <br /> FEE:$� <br />