Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> DATE — ZZ_ 12 MASTER FILE RECORD INFORMATION"MFR" ORFS FORM <br /> SITE MITIGATION&LOP <br /> SHADED AREASFOR EHO USE ONLY ;:OWNER ID# CASE# <br /> �NIT IV <br /> OMER FILE.COMPLETETHEFOLLOW/NG PROPERTY OWNER INFORIAAMW. C/ECKIF OWNER CuaaEN?xyoNFItETrm END <br /> PROPERTY OWNER NAT: <br /> First MI Last PHONE Nuumm <br /> BUSINESS NAME E-MAILADDRE33 } <br /> M'evl ear ii, OPAs <br /> Owner Nome nddreas <br /> City STATE ZIP <br /> Owner Mailing Address <br /> r l�r ✓Q <br /> Mailing Address cies 211, t3 383 3 <br /> CUitPORA7tON� INDMDUAL❑ PARTNERamip0 "FED AGENOY❑ OTHER❑ <br /> I <br /> srm MmOATwm^BNvmomcmrAL AmESSfAENr)VOLUNTARY CLEAKUP_WATER QUALITY_FiCI PIPELINE hiVESMOATION_LOP_ <br /> FADILtSY ID# -....:: -,:..;:.1►n!q. :..: AcgouNT ID'_.: /R0#'.. -/►sals+►3EDll1 -Y = LI=J!o A�EwcrEHTi' _----RWQC D'T !O=• ERe <br /> Q'A_:: s <br /> :.. <br /> FACILITY FILE COA/PLETF-rHEFOLtOW/NG BUSINESS/FACILITY/SITE INFORNATION.' <br /> i <br /> Is this a NEWBusiness LOCATION not previously regulated by the EWOONMM&AL HEALTH DEPARTMENT? YES ❑ NYm i <br /> Is this an EMSTING Business Lom-nom but/a NE��w]TYPE of regulated Busine�s�tsA? / YES ❑ No <br /> BUSINESSIFAaLITYISTTE NAME <br /> STTEADDR[�.9 96D SUITE# BUSINESS PHONE <br /> CITY L STATE ZIP <br /> 13OAItD OF SU PERNSORDiSTRICr Lowen CODE <br /> KEY2 <br /> Mailing Address YD1FMMrfAXVFraVftAddrsatr Attention:arCare Of ApAxoP <br /> Mailing Address Cily STATE ZIP <br /> $ICGoDEOFew <br /> # ' cam CortTaENr _ <br /> ..:........... ... . <br /> THIRD PARTY BILuNG INFO". Complete if Billing Party is different from Property Owner orFacility Operator idenffhed above. <br /> BUSINESsNAME (/ S AttertHon:orCaToOF(opabrtmq �91&1.OKI 'A"dt <br /> Mailing Address /do r L.V 1` <_1L t&i7-tLK ,� � Z�/l/ PHONE //D� <br /> CITY �C STATEZP <br /> Aforfees and charges OWNER FACILTTY/BUSINESS TFaRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: f,the undersigned Applicant'certify that 1 am the owner,operator,or Authorized Agent of this Business,and I acknowledge that all PERHIrFF.r s, <br /> PFj1GLrrES,ENroRcEmEmrCHARaw and/or HOURLY CHARGES associated with this operation will be billed tome at the address Identified above as the AcromvrADuxscs 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 JOAQM, 'ry CouNOrdinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations.As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same tune itis <br /> provided to me or my representative. /► / <br /> APPLICANT NAME(PLEAsa PRw) SIGNATURE <br /> TITS �e6�Gy�s� TAX ID# <br /> Approved BY Date Ae ORiee Ptoeesaing Comp btad e / � Data <br /> SII'EkIITOATN)N-. AMOIINT PAID -.': .DATEOP PAYaIEIiT .PAYMENT TYPE ;RECEIPT.A- CHECN:# RECEIVED RN <br /> II7+ <br />