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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATEl `` MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> 7-r�m SITE MITIGATION&LOP <br /> BIMOEDwnFwa Fon END USE ONLY OWNER IDt CASES I UNIT IV <br /> OWNERFILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CNECKIF OWNER IS CORREATLYDN HLEHITH END El <br /> PROFERTYOWNERNAME EddLi 'Tb (2ei�/ L . <br /> FIRST M, FAST PHONENUMBER <br /> BUSINESSNAME �1 _ I EiMILADDRESS <br /> �a.�� Y(` l� e Psi s. C <br /> ynNEA HOME ADDRESS <br /> Cm STATE ZIP <br /> OWN"MAIUmo ADDRESS a 5 a-6 Ca. .bel a <br /> IMILIND ADDRESS CITUf u ��// STAT! ZIP <br /> ❑CORPORATION El INDIVIDUAL El PARTNERSHIP [:1GOVERNMEHTAcI 2<1 PONSIBLE PARTY / ❑OTMEL <br /> SITEMITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LQI_ <br /> FACILITY IDt fA/ INV/ ACOoUN�nrIII�D��( PRNRO# Aa Nordso EMr1GKE LEADAGENOWEND_RWQCB}(_OT —WI <br /> T oJI D �"1 Y"`I� S.u/'7'y NY.0modk y <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS ANEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YEa ❑ No <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YM No ❑ <br /> BUSINEssIFACILFIYISITEJPROJECT NAME ^r }Rr r e- �^ <br /> SITE ADDRESS I PITWeef LOCATION �A.v) P r L SURE# BUMNmpmma <br /> I1�yI .�'T� 4. I Lam' ( r <br /> Cm 5 C'll- ' CTA— <br /> BOAROOPSUPERVISORDlB OT / LOCATION CODE / KEYT KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTEWKIN:ORCARE OF(O/DONAL) <br /> MAILING ADDRESS CITY STATE ZIP <br /> SICCo.E APNt/ 0 CORGIESI K) 93 J <br /> THIRD PARTY BILLING INFO:COMPLETE tF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTVXD ABOVE <br /> - <br /> BUSINESS NAME L f -S (1 _ ATTENTION:ORCARE OF(O/PQYAL) v//Lqt <br /> UL LJL� <br /> MAILING ADDRESS PHONE• n i ,,�T ry / <br /> L o Tll`�1F <br /> Cm I/� 11D%- tlorf Sa <br /> STA Lr <br /> 11,3 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER FACIUTYIBUSINESS❑ THIRD PARTY BILLINGB� <br /> BILLING AND COMPLIANCE ACN.NO WLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Opemtnr,Awhorifed Agent,or RerperAb a Party end I acknowledge dust a0 PeRe rr FEET, <br /> PYNALT/ES,EN£ORCEHEM CHARGES and/or HOURLY QIAR6Ee associated With this project will be billed tome at the address identified above.the ACCOUNTADDRESP W this 3114 I ab*Ca"BMt SU <br /> information provided oa tNs application Is true end cnrrecq and Mat all regulated activities will be performed In accordance with it applicable SAN JOAQUiN COUNIY ORYINRNcg CODES and/or <br /> S,A .AROs end STATS and/or FEOEIAI.Laws end REGULATIONS. M the mal rsibmed Owner,Operuror,ARlhoriud Agent or Responsible Party for the project located above under fadiityMk mistress,I <br /> hereby authorize the release of any vad all resWis,reports,and other environmental assessment Infnmati0n t0 SAN JOAQNN COUNTY R.VVIR <% WAL IILALTH DEPAHTMtW as 5000 B it 6..Mable <br /> and at the same time it is provided to me or InLDpresenktim. (((111 <br /> APP LICANT NAME(PLEASE PRINT) ,tonoL�1 n� �V('e'Z-�tRSC r� • SIGNATURE <br /> TITLE QO(o5r sr— YL `� TMID# <br /> APPROVE.BY DATE l•J ACCOUNDNGOFRCEPROG.R.O COMPLETED BY DATE <br /> SITE MITIGATION AMOUNT PAID DATE OP PAYMENT PAYMENTTVPE RECEIPTS GRECIAN RECEIVED BY WORK PLAN PE <br /> FEE:; <br />