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Fl" <br /> San A),uin County Environmental Health DEpartmen������� <br /> DAA 3 -amu ao/2 MASTER FILE RECORD INFORMATION"MFR" 64EUMRM <br /> SITE MITIGATION& LOP <br /> $HADEDA A8 OREHDU USE ONLY OWNER ID# E VIRON -'��y1 <br /> CASE if PERMnI�yIf; <br /> Eltr <br /> OWNER FILE-COMPLETE THEFOLLOW/NG PROPERTY OWNER/NFOR��M//AT/ON.- CHECafF OWNER CURREAULYONFiLEfmn/EHD <br /> PROPERTYOWNERNAME Dao ie/ Mc 6i/`G Ole <br /> cam' - Asa -yIV?o <br /> First MI Last PHONENUMBER <br /> BUSINESS NAME <br /> S �X CO/'vJ Ara 74/Or7 EawLADDREss / <br /> Owner Home Address da�t'/FrC �Ofde <br /> /35/5 /3u/1ary7r ne Go�p9,Afe s�/Ace <br /> city / <br /> G h a r1b 7�_e SATE zip <br /> Owner Mailing Address <br /> s ficf.P <br /> Mailing Address City[ <br /> Sa/net(S a/loke State Zip <br /> CORPORATION INDIVIDUAL.El <br /> PARTNERSHIP El FED AGENCY❑ OrHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP X WATER QUALITY_NW PIPELINE INVESTIGATION_LOP_ <br /> FACILITY ID# INV# ACCOUNTIO PR#/RO# <br /> ASSIGNED EMPLOYEE LEAD AOENCY:EHD_RWQCS K DT$C_EPA_ <br /> 10 P2oa9�Z l/ OQ <br /> FACILITYFILE COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE/NFORMAT/ON.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No �X <br /> Is this an ExISTING Business LocnnoN but a NEW TYPE of regulated Business? <br /> YES ❑ No <br /> BUSINESSIFACILm/$RENAME <br /> SmSADDRESS <br /> r�60 /I/O^ 9 �G SUITE# BUSINEsSPHONE <br /> YI' nN� ffre <br /> Cm Y / { <br /> STATE ZI'fP 2 r S <br /> BOARD OF SUPERVISOR DISTRICT 1 LOCATION CODE Kerr t' <br /> h KEY2 <br /> Melling Address"IFFERENTIrom Fact#lyAddress Attention:orCere Of <br /> 135/5 /3A //aof tie Com D�artC� O/tile tevaaRa/r <br /> Mallin Address City <br /> a n:E/ qyl[ �rraC�P <br /> Ch 4-/o fire STATE zip <br /> SIC CODE qpN# <br /> THIRD PARTY BILLING INFO' Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME <br /> g✓H 19 'wen:C a (Foy Bi �JvFi Able on: <br /> �%re of toP1/omr// <br /> Mailing Atl��d/fress <br /> 3 L �0 vYP L ✓l R �� PHONE <br /> CITY <br /> Sa r^qt rne/T+ `J sTA zIP <br /> � 9ysa6 <br /> A cot�aRF_for fees and charges OWNER FACILITY/BUSINESS <br /> THIRD PARTY BILLING <br /> Bu.ux.AND Cmtrl.uvo AC6 V0\\'1 rocnlrn': I,the mlJcrsigned Applicmrt,ctrtJy Thal 1 am the Oa•neq O ernroq nr Aofhori-sd A yen <br /> Peva nr s,Evroxci vLv 6/,wces:md/or//otxzr CzzlxeL.ctissociate)with this operation will he billed In me al[headdress identified above as theBAsct'nrYiAnnxcss forlth ses,hattalll oex?rfifv Ihaf <br /> all information provided oa this application is true and correct;and that all regulated'dirith will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and SLAIL and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/sin,address,1 hereby authorize the release of <br /> any and all results and environmental assessmenl information W SAN JOAQUIN COEN'I Y availaM1le ad at the sa <br /> ENYIRONNIENTAI.HEALTH DEPARTNIRN'1'as sois ame lime it' <br /> provi&d to me or my representative. on as it <br /> APPLICANT NAME(PLEASE PRINT) tHr�� 9,Yh e SIGNATURE 110 \ ��✓1y�y. <br /> TITLE/ <br /> TAxID# d / <br /> IV <br /> Approved By Date Accounting Office Proc s"I g Completed By <br /> Data <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# <br /> FEE:$ CHECK# RECEIVED BY WORK PLAN PE <br /> 29Go <br />