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San Auin County Environmental Health eartment <br /> DATE 11 114 l I MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> IIIS�H/I /� SITE MITIGATION & LOP <br /> SHADE FASO EHDU O OWNER IDR l 1361' CASE# SQ-XD63�69 UNIT IV <br /> rrrCCC��� 6 8"7m0 <br /> OWNER FILE:CoMPLETErwFoLLowwPROPERTY OWNER/NFoRMA770N.• CHEEKIFOWNER CURREA' VMRa LFIMTNEND� <br /> PROPERTY OWNER NAME <br /> rt avYo (zW)Li7o- 3 oS <br /> Fust Ml Last PHONENUMBER <br /> BUSINESS NAME E•NAILADDRESB <br /> Owner Hahne Address <br /> Z(Iy AZ4e VeAwe- <br /> Clgr <br /> 54-ock4or\ STATE <br /> 452v8 <br /> owner Melling Address <br /> 264 u1� f 12otD.c( <br /> MWIYIp Addrsss City Staff LP <br /> Stockton CA 9SZ05- <br /> CORPORATION❑ INDIVIDUAL® PARTNERSHIP❑ FEO AGENCY El OTNER❑ <br /> SRR MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVRSTNIATON_LQP <br /> FACILITY IDR INV# ACCOUNTID PR#/ OR ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWgC DTSC_EPA <br /> -1109 3t79�9 os3(013 bz(q <br /> FACILITYFILE ComPLE7F7HEFoLLOWINCBUSINESS/FACILITY/SITE/NFORAunoN. <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No �f <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> EIUSINEss1FACIUTYISITENAME <br /> fvn2r SI {001(} CON U 'YtiOh <br /> BITEAoDREes <br /> 'Z <br /> 1. <br /> 02'{ S. Avvle.ri vx STrE# BUSINESS PIKINE <br /> zo <br /> $UTo 70. 905 <br /> CITY I I <br /> s4o.LI N STATE ZIP <br /> i� <br /> BOAROOFSUPeavisoRDISTRICT LOCATION CODE KEYt H \/1'�1 <br /> Mailing Address MDIFFERENTYYDraFsamyAddress Atbentlan:arCare 01/apN—# <br /> Mailing Address Only STATE ZIP <br /> SICCODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party iS different from Property Owner or Facility Operator identedabove. <br /> BUssiess NAME <br /> Wr r k 1 Attentlon:orCare Of tapffa,,Q <br /> Mailing Address PRO <br /> 23 64 r ur "I Su IS-0 C�NE NE <br /> CITY SaSTATE ZIP <br /> no ROSH c fl s40-7 <br /> AQ(d tffia O�Aq for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Oxwery Operator,or Authorized Agent of this Business,and I acknowledge that all PERM/TFEES, <br /> PENALTIES,EN£ORCEMEATCHARUES and/or HouszYCHARGES associated with this operation will he billed tome at the address identified above as the ACCOONT'AHORES.e for this site. I also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COINIT'Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations.As the undersigned owner,operator,or agent of the property]orated a Bove ' /site add r ,1 hereby autharire the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D ART T as s as it i available and at the some time it is <br /> provided to me or my representative. ^� <br /> APPLICANT NAME(PLEASEPAINT) Jt y/S %UY\O�UC SIGWITIRE <br /> rrnE TAX <br /> A - o ? - 49 / x!MCI <br /> Approved B Data Accounbng Omoe Processing Completed 6y DebSITEMITIGATION AMOUNTPAID DATE OF PAYMENT PAYMENTTYPE RECEIPTR CHECK# RECEIVED BYFEE:$ .zi}5,00 � Ibl°IIZ W <br />