SITE INFORMATION AND CORRESPONDENCE

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PntmIr ,tq, 1 h 14 skGCo1G3S Sale' uin County Environmental Health Department DATEMASTER FILE RECORD INFORMATION"MFR" GREEN FORM F[Wln)� �� _ - .._.—_. — SITE MITIGATION & LOP SHADEPaR 9OREHDUSEONLT OWNER ID# CASE# UNIT IV OWNER FILE:COMPLETE THEFOLLOW/NG PROPERTYOWNERftroRMAT/ON.' Cwrorur OWNER CURINVOIL ONFR.Ewire END PROPERTYOWNERNAME DL) G = I 116/r I H , First MI Last PHONE NUMBE Z. Q BUSINESSNAME E-MAILADDRESS m,11 rZ Ownerome Address City / /1/9 STATE ZIP Owner Meiling Ad 7-,'-(17,W- 1/Vn 7 O Mellllg Address City Zip CORPORATION INDWIDUAL❑ PARTNERSHIP❑ FED AGENCY 1:1 OTHER❑ SITE MITIGATION_ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP FACILITY ID# INV# AccoUNTID PR#1 RO% ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB DTSC EPA oo� yyl P o oss�� 0 8�1 FACILITYFILE COMPLETETHEFmLOW/NGBUSINESS/FACILITY/SITE/NFORMATIoN• y Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No.T 7 Is this an EWSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO>K BUSINESSIFACIL"ISITE NAME 1 , SITEAODRESS w SUITE# BUSINESSPHONE CITY / $TATE ZIP BGARDOFSUPERVISOR DISTRICT LOCIITX)N CODE KEY1 KEY2 Melling Address B'D/FFERENTfrom Fac##yAddress Attention:orCare Of topsona9 Melling Address City STATE ZIP SIC CODE APN# COMMEM: THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. BUSINESS NAME NB OR OFCar'e Of,fOQi/O Q 50�rCrz C, � Melling Atltlreae S PHONE Cm �,s7�TEIr AGFp//AUAOOBES4 for fees and Charges OWNER FACILITY/BUSINESS �►Y THIRD PARTY BILLING BILLING AND COMPLIANCE ACNNOWLEDGMErvr: I,the undersigned Applicant,certify that I am the Omner.Operator,or Aorharixd AReul of this Business,and I acknowledge that all PE2D/TF££$, PENnLTios,EvroRCEm£nv bMse£sandRi,RonsuCHARGEsassuciated with this operation will be billed to one at the address identified above as the AAToi N ra DDa£5s for this site. I also certify tbal all information provided on this application b true and correct:and that SII regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE andlor FEDERAL laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above faeiliry/site add'A s,I hereby authorize the release of am'and all results and environmental assessment information to SAN JOAQUIN COUNTY ENYIRONMENT.AL HEALTH DEPARTMENT as soon as i available and at the same time it is prnvided to ane or my representative. APPLICANT NAME(PLEASE PRINT) vfs+ SIGNATUF TITLE ,O TAX ID Approved By Data (/ Accounting Mee Processing Completed By Data TSITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT% CHECK# RECEIVED BYORN PLAN PE FEE:;