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San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION `LMFR'r GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHO USE ONLY Omm IDN CASE# UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOW(N&PROPERTY OWNER INFO{{RMAT/OM. CASaracOWN ERCURRerritYON£aEWnHEHD0 <br /> PROPERTYOWNEa NAME CN(L�S eA0 V (11Kto - X 3 6 0 <br /> First MI Last PKONENUMaER <br /> BUSINEssNAME6MULAODREss <br /> wM1Tt ReP-oLILY cN�Isc�I�NIrE �z . <br /> Disinter Homs Address <br /> Ave <br /> CRY <br /> STATE 6vto }e be( �o CIA nP Ola LCCA <br /> Owner Melling Address VAq'IL Ade <br /> Melling Addsass City LA/t0 e�Ae b e LL(.) Stale LP / Y <br /> CORPORATION EK INDImouAL❑ LUFASHIP❑ FED AGENCY❑ ONME] <br /> SIR MMGATON_ENVIRONlinKrAL ASSESSMlNT_VOLUNTARY CLEAANNCNUP WATER QUALITY_HVJ P IPELJN E INVeEnnsaTioN_LOP_ <br /> FAxUuTv ID# INv# AccouMlD #1 O AssIGNEO EMPLOYEE LEAD AcENcr:EHD�RWQCB_DTSC_EPA_ <br /> 12-15 3 S oo,,LM, i4 �i <br /> FACILITYFILE COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMEhMAL HEALTH DEPARTMENT? YES 11 No ElIs this an ExiSTiNG Business LOCATION but NEW TYPE of regulated Business? YES 1 No ❑ <br /> Busxess/FAcIu1YIBRE NAME 11 L <br /> U <br /> SREADDRE83 <br /> S� BUSINESS;PHONE <br /> �`ADDL 6 , p. (- g <br /> Q" <br /> DCKTDT� Cry vP�s��� <br /> BOARDOFSUPERVISORDIMICT LOCAnONCODE KEel FEY; <br /> Ma III ng Address HDIFFERENTirom FaeIIHyAddroaa Atlentlon:orCareOf(opNona <br /> RECEIVED <br /> Mailing Address City STATE zpAUG 19 2014 <br /> SIC CODE APN# CAMMeeT: SAN JOAQUIN COUNTY <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Opera <br /> BUSINESS NAME Attention:orCate Of(optional/ <br /> Melling Address PHONE <br /> CITY STATE ZIP <br /> AccopovrAOORFCR for fees and charges OWNER FAclUTYIBUSINESS THIRD PARTY BILLING <br /> BILUNG AND COMPLIANCE ACKNOPLEDQIENT: 1,the undersigned Applicasd,artik that lain the Oa'nery Operator,or Anthorized Agnrl of this Business,and 1 acknowledge that;ill PEnRIi'FEEV, <br /> PENAzzia,EN£ORCEV£NTCIURGEv and/or NOUiNFCINRGES associated with this operation will he billed tonic nn the address identified above as the AMOUMAVIIRESS for this site. 1 alto rertify that <br /> all information prodded on this application M true and eorreeh and that all regulated activities will he Performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes andlor <br /> Standard sand STATEandtor FEDEMLLalrsaed Regulations.As the undersigned owner.operator,or agent of the property located at the abovef ility/site address,l hereby authorize the release of <br /> any and all results and enYlronmenhl assessment tnfonnalion to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART T• sno s it h nviultible anJ a same time it is <br /> Provided t....r my representative. �� <br /> APPLICANTNAME(PLEASE PRIM) (J n, �... SIGNATURE <br /> TITLE �{✓(i~UV,\9, r� AA 0 A O2 TAX I D# <br /> Approvotl 8y Deb 11 AcccuntinDODica Proccala,Complabscl Deb <br /> SITE MIIG[A/TION A/MOUNT PAID DQAT'E O)F PAYMENT PAYMEN/TTYPE RECEIPT# CHECK# I^s RECEIV D WORK PLA�DPE <br />