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• <br /> San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADED- AS FQRRFHDUSEONIY owl—,ID# UNIT <br /> IV <br /> OWNER FILE:COMPLETETHEFOLLOWING PROPERTY l/OWNER✓INFORMATION: CHECKiF OWNER CURRENTLYONFILEwrm EHD <br /> n— � A , _ <br /> PROPERTY OWNER NAME ( Cal tT�rn l(� IVn Li i�-14 VEP{� RIG `�j 9-�44 � ---V- <br /> First Mi Last PHONE NUMBER <br /> BUSINESS NAME K „ E-MAIL ADCRE5Sa,�ta �y �tGr, ^r� <br /> ma-fi��,W low I. <br /> Owner Home Add(6r - • �B(V e aVt' lM�p/� me l <br /> City U M �_I_d ` 11( /��`� STATE ^ ZIP a•� <br /> 1 <br /> Owner Mailing Address <br /> Mailing Address City Stats Zip <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER <br /> SITE MITIQATION ENVIRONMENTAL ASsESEMENT_ OLUNTARY CLIPANUPX WATER QUALITY HW PIPELINE INVEsTtGATION LOP_ <br /> FAaLtTY ID# INV# AccouNTID PR#IRO# � 6�LOYEE� m-' <br /> V8 AG�Lw EHD' ,_J21M1��iCB DTSC'� ESA <br /> I' f � <br /> A'DD 2 q D �::��.� <br /> FACILITY FILE COMPLETE THEFOLLOWING BUSINESS FACILITY SITE INFORMATION: <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 /> BusiNESSIFACIUTYISITE NAME /'`r—rK-fM CS&AS _ <br /> SITE ADDRESS802,� ^, Y SUITE# BUSINESS PHONE � <br /> STATE <br /> Crrr � lr„1�f/-l� L,tj <br /> BOARD OF SUPERVISOR DISTRICT LOCATIOtt CODE KEY1 KtY2 <br /> Mailing Address it'DIFFERENT horn FacilityAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE � APN# � COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> Mailing Address PHONE <br /> Cm STATE LP <br /> 4kaZMTA0MW-for fees and charges OWNER FACILITY/BUSINE5S THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the O—c, r '`d.tgcnr of this Business,rind I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCE.MEVT CIL4RGES and/or 110URLYCHARGES associated with this operation will be billed to me at the address identified above as the AccouNTADDRESS for this site. I also certify that all <br /> information provided on this appllcatiun is true am]correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNrY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facillty/Ote address,I hereby authorize the <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DFPARTbiENT as soDn as it is available and at the 52mr, l <br /> provided to me or my representative. ``\\ ..�• J,� / �F�1.1c <br /> APPLICANT NAME(PLEASE PRINT) \^^_:-1sr� „tea. Y4il�,nt�p_ SIGNATURE I, ��a r <br /> TITLE � Y'� ! n/�.A, S11555&" �y 'rmi �� Tax ID#NA 2014 <br /> l.b'f('[ J"i SAN,1pA <br /> 7 Wr�N71 <br /> Approved B Detre Accounting tmce Processing Complelad sy Data 0 �EP aC' <br /> SITE MITIGATION AMO/UHT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY .WORK PI.wN PE � `� <br /> ' FEE: Ll i ?iq <br />