Laserfiche WebLink
+oJ <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE _ ( J, MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION& LOP <br /> SNADEDMEABJDAENO.510EONLY OIYMERIDS hl/l,.o/—/Q� I CASES 49WI,67GG UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNERI RESPONSIBLE PARTY INFORMATION: CxEc.YVOwWER/e cuawEWnravPAE HTF((END <br /> PROPERry owNEn NAYElG G ()�J,.l� <br /> FlFsf MI Lac, PHONE NUMBER <br /> BUSINESS NAME ,( pvc <br /> �/� L G <br /> ILJ <br /> OWNER HOYEADGRE88 <br /> 4I'S G2L4Wu)iI'w p- 7 <br /> Crr,r - STATE Me <br /> OWNER MAILING ADDRESS <br /> MARINO ADDRESS CRY SITc- IV\C <br /> STAT <br /> LP <br /> El CORPORATION (�❑IHONIWAL LN�PARTNERSNIP ❑GOVERNMENT AGENCY [IPOSI <br /> RESN /S`]LE/'1`PARTY y VX❑OrOrtim <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP WATER QUALITY HW PIPELINE INVESTIGATION LOP <br /> FACILITY ID ?6SSIGNENAoHDtiEAMPLOYEE QCB_DTBC_EPA_ <br /> bB m AQDD Wo53 <br /> y <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: 3 <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES ❑ No <br /> BUSINcssIFACIGTYISREIPmECT NAME <br /> SREADDRE33IPROJEDTLO%1TKW J r I ls- SurJEN BUame"PHONE <br /> 1— 2-S Esk MVAeC' 1 N� VIkC _9 <br /> CITY SkbLLkv V1 cX7 <br /> LP — <br /> BOARD OF SUPERVISOR DISTRICT LDGTIONCWE KErt NEr2 <br /> MAILING ADDREaa,IF DIFFERENT FROM FAcBr Y ADOR"S ATTENTION:ORCARE OF(LWFN.WAE) <br /> MMUNG ADDRESS CRY STATE ZIP <br /> SIC CDDE APNN COMMENT: <br /> 07 - H2o -o <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME C TTEN—ON:OMCARE OF(OPFJGYALJ <br /> J G- <br /> MMUNOADDRE86^ !'�� PHONE <br /> 1 9 _ <br /> q <br /> CRY STATE bP <br /> ACCOUNT ADDRESS TO SFNG FEES AND CHAROES: OWNERO FACILITYIBUSINESS❑ THIRD PARTY BILLI <br /> Iln l nc ren l Vlefl lrsl l' U Nwu 1 PN:Gf sT: L the nnArniFnal \PPii.:nn.,coif,lLal l nm On Pnruv.Olrtngrn,-Dr//Nni;rvl.l;fn/."F R.+INrrr.ihlr l't r.I.nd l nrblmrledCe lhel ell PENT///I9/.. <br /> 1-1\D"l.../1/rm'r1.u(s/UIIxnl f:nAU4!IID/N"fErm."arcncialnl�id.III,prnjnitrill Df hillnl l4...mdiV:LTlhnaW Frlirl Thalall <br /> nr41111:11i411 I. irlNl.m Ilri.al,lrlirali4n i.Irrrf xad ror.l;stud that left F.::Ilmo arti.ilin"ill In IN•rf41'111M1I it.arr'4nI:NNc NiNI nil:Hli,lu'Alilf NIs.III UJLI\f'nl\I\ flRnn r\!r f Inn.::n.l'.F <br /> FI rsuunn and 5n1[nnd�nr 1'1'lll'N.1.LarrvnNl Nrt:rn rouse. %'11V undrniCml(INnel,it,,, , IIIIh,ViptL IRa'I//.nr R......:n.Ale Pam fnr IIV PFujerl lnl:IRd alma•nndrr LYiliy6Ar adJ,c...I <br /> IIF'Ialn amhnrilr tln nMn.c of am...Xl 411 ronin.rt n,.nnA�nhvr rn.inn4m..ul.....�..maY infnrnuuhm m Nu.lo rVl n 1 DI.II hsl MKm il'i%1,fit.O.III H F%EE1II:]1 as <br /> and:n tlm.:n4f limy,it n PF...0M L,... a nn rrpmanulirf. I, <br /> PVPDGNT NAYE(PLEABE PRIM) '/F'R- Ts(,,f+4 t Q (-EFL SNNATURE -. <br /> ��`iWJ 4 <br /> TITLE c eo S. Q... _.�.. .-Fa V LV.r�-��� TUIDS <br /> NPRWmBY I I'OAA'T!"T/` ACFWMIND OiFICF PROCFaaIXO COYp{t1ED 8Y DAl! __ _ <br /> 8rtl MFEIGNBON AMOUNTPMD DAWWPAYMENT PAYMENT TYPE RECEIPT6 CNFCKN RECEN�y BY WORK PTAH PE <br /> FEE:SJ7s !� - 3II5 vlskL, a�5� <br /> °Ib8?Ig <br />