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40 10)T a 04 D <br /> 0ts 6aw!,4wv <br /> -8 e tkAv <br /> q1 At re U 9 4-o c k4-6n CA 9 S2 0 S <br /> San Joaquin COLHity Environ Thal Health Department Aff n'.tA luel an <br /> DATE IMASTER FILE RECORD INFORMATION"WR" GREEN FORM <br /> I I ------ SITF MITIGATION&LOP <br /> 9m'( OWNER 1139 UNIT IV <br /> OWNER FRLE:COMPI THEFOLLOWING dW-NER INFORNA7701W CNEI 7F Ci NF_R CaRR.-maromrxe wnrti ENO <br /> PRO PEPT y OMER 0 <br /> RIG --%9-445-`eH <br /> �-E Mi % <br /> Fire m) Last Plione NumsEn <br /> BUSINESS NAME <br /> Owner Nome Adlrt;,2, MaH <br /> Jjqr 6(Vj <br /> G <br /> City STATE <br /> Owner Mailing Addrust; <br /> Mailing Address City State Zip <br /> ----------A— <br /> P HIP 0 IFEnAGENCY El OTHER <br /> CORP..Al-I..D INDIVIDUAL El <br /> ?oLPjmTARyCLmmuPX WA-rE1lzQtJAlL1TV—iii PIPEUNI!9NVl2ST`lr.AT11Gm--LOP <br /> FACILITYIDA NV AccoupirlD PROIR)W <br /> Ii-ACOLUTFOLE COMPLETE THE FOLLOWIfJoBUSINESS1 FACILITY/SITE ImFoRwnom- <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIM)NMCNTAL HEALI'o DEPARTMENT? YFs 0 No <br /> Is this an ExisfING Business LOCATION but a NEw TYPE of regulated Bus ness? YES El No im <br /> BUSINrSSWACILITYISITENAME QCC-KjcM 0-S-&AS <br /> SITE ADDRESS SUITE 4 BUSINESS PHONE <br /> Sot D S. Al 2'"' <br /> STATA ZllqS?06 <br /> DOARL)OF SUPERW60._.[ L..ATI.I �KEY2 <br /> Mailing Address if171F,'6RENrfyvny racifityAddrEiss Attention:or Caro Of(vpfianvl) <br /> Mailing Address;City STATE zip <br /> SiCCaDE APH P <br /> T"IMP PARTY RILLUNG UMFG. mpje To iF13111 Inly Party is different from Property Owner or Facility Operator identified above. <br /> BusiNEss NAtAll wM Attention:orGaire Of(aptlonaf) <br /> Mailing Address <br /> CITY STATE Zi P <br /> ifll.Ll N("hNn dn:0aii t t(.tase ACHNOWI.EUCRIENT: 1,the undersigned Appilcant,certify/last F ani Lhe(1nTrc�Pv-Q;aawntp�,AxeSadk�' Agcn1 of ILvs Business,and i aeknOtvlydgr.that all FErihn7..I'+CES, <br /> P2NALT/Ei,F(�'FORCEhrEM C1LtW(wBSAndIUr/(ALrRLYCIL/R4"F.S aSfn�iAtali WIIiI dti9 nj)fira Ci Olp wilt tit b{IICII lV m0 ni UIC adlire53 Iden Hfieft abnYC a5 fete rCnurr nnR Ess for feels slfe.I rxtsn certify the/nli <br /> inforr"Quilinn provided on this ipplIcilhat h true anti correct;and that all regulated activities v,ill be[Krformcd In accordance wilt/all applicable SAN JOAQUIN COUNTY Ordinance CO(les and/or <br /> Standards And STATE and/or 14awitAt.Laws and Regulations. As the toulcrallined owner,pperplor,oragent of lim Property located at the abom-faclifty/fifte adifintis,I hereby nathor4t the release of <br /> anyand all resultsanti information to SAN JOAQlJ Ni COtnNTV ENVIRONMENTAL HEALTH DIEPARTMENTas anon as 11 is at,allabic and 2fthe same time It is <br /> provided to nu or my rrIa-s*cPaaIiyc- SIGNATURIZ%D, <br /> APPLICANT NAME(PLEASE PRINT) <br /> TITLE,: PLV�P-C-'6r ARefia TAX NA <br /> ............ -------- <br /> Pm Colo Datm <br /> ITO <br /> T �:NECit <br /> ym <br /> N, Ufff PAID aff'dOv V'AiM9V'C- V"A' a I' V RF.CE'lVED By PC., <br /> MITICCIA11ON <br /> t5 <br /> .................... <br />