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l� 00d34 J 4 3 <br /> San Joaquin County Environmental Health Department <br /> DATE / _ 7_ MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> > SITE MITIGATION&LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETETHEFOLLOW/NO PROPERTY OWNER INFoRmAriaN: Om malt OWNER CumemmYavnLewrmrEND El <br /> PROPERTY OWNER NAME 20 P�6s/J 1— 1 <br /> F//st Mf vv Last `PHI ONENUMBER <br /> BUSINEss NAME _ (C1 E-MIULADDRESS <br /> I�cL C< c�S CLK� �2(�' 1 L 6z} r—M A <br /> Owner Home Address <br /> City STATE zip <br /> Owner Mailing Address 3^ <br /> Malling Address City ( i stetsZIP <br /> CORPORATION 1;,� INDIVIDUAL❑ PARTNERSHIP❑ FEOAGENCY❑ onm Ej <br /> SITE MITIOATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# IHV# ACCOUNTIDPRNM# ASSIGNED EMP OYES LEAD AGENCY:EHD RWQCB DTSC_EPA_ <br /> OZdZS 053�wi� 0�8� <br /> FACILITY FILE C041I THEFOLLOW/NQ BUSINESS/FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No UL <br /> Is this an EXISTING Business LOCATION but alNEW TYPE of regulated Business? / YES ❑ No <br /> BUSINESS/FACILITY/SITE NAME <br /> SITEADDRESS 'l V I` U( `fn _ SURE# BUSINESSPNONE <br /> Cltt STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATIONCODE KEYS KE-2 <br /> Mailing Address ND/FFERENThnm Faclll1yAddress Attention:orCare Of(optional) <br /> 211) ( CY'6,w C" <br /> Mailing Address City STATE ZIP <br /> SIC CooE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Bllling Party is different from Property Owner or Facility Operator identiledabove. <br /> BustNEss NAME Attention:orCare Of (optional) <br /> Malling Address PHONE <br /> CITY STATE ZIP <br /> AnciouhTApa n for fees and charges OWNER, FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND CONIPLIA\Cr.AcKNow LEDCNL\C I,the undersigned Applicant,certify that I am the Oitwer.Operator,or.tuthorized.lgent of this Business,and I acknowledge that all PERIIrrFEE.T, <br /> PE.v:alnfc,E.YroRt'EvE.vrCit.urGEs and/or lluCRLrCMARGES associated w itb this operation w ill be billed to me at the address identified abose as the Acrut'sT.tnnRExs for this site. I also certifi that <br /> all information prosided on this appGcafion is true and correct;and that all regulated actisifies will be performed in accordance with all applicable SA.\Jo.\QL'IS Cot,-n'Ordinance Codes and/or <br /> Standards and STATE.and/or FEDEM Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,l hereby authorize the release of <br /> any and all results and erwironmtnml assessment information to SA\JOAQULN CON'\fl'ENVIRONMENTAL IIEALTII DEPARTME.T as soon ny sam <br /> it is available an a1 the e time it is <br /> prosided to nit or my reprtsentalive. // 7 (p <br /> APPLICANT NAME(PLEASE PRINT) izya�� 1 G .y y SIGNATURE <br /> t� <br /> Tent? eEA?6Wt7M /r! ' ��il!'1�i / TAX ID#rl ;u Cf (A -- 0--7 y Z�O � o <br /> FApproved By Data Accounting Office Processing Completed By DaE MITIGATION AMOUl1T PAID DATE OFPAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAF't <br />