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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE _ (J, MASTER FILE RECORD INFORMATION`'MFR" GREEN FORM <br /> SITE MITIGATION 31 LOP <br /> sXMEOAPEAs fOq EHOVBEONLY OWN"IW CAs[O UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CNecN/F OwWEIYM CWREML rOWFile WEN EHD� <br /> PROPERTY OWNE.NAME `� n <br /> /'}� FINsr MI LAsr PHONE NUMBER <br /> ES <br /> SusroS NAME .r c ,! 0'�� Ln E-MMLADDRESS <br /> N r .c <br /> OWNER HOIIEADDREss <br /> 11'ss (2Y2ue.�WuLil'w eIU� <br /> CmSTATE LP <br /> EL zsoCa <br /> OWNER Ill ADDRESS ^ '�� SS1o� ` I Jl• <br /> lVl IY\ <br /> MAILIND ADDRESS Cm STATES LP Q S$a J <br /> ❑CORMMTION`\] ❑INDMWAL B il.ERSHIP ❑GMERNMENT AGENCY ❑RESPONSIBLE PARTY' ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP.__WATERQUALITY _.. HW PIPELINE INVESTIGATION LOP_. <br /> FAcILm IDf INV/ AcccuxT ID PRO/ROA ABSIGNEDEMPLOYEE LEAD AOEHCY:EHD_RWQCB_DTSC_EPA_ <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS ANEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No <br /> 6USINESsIFAGIUTY1SfTEJPR0IECT NAME ' ` Qc<�rj PLAZA A <br /> 8RE ADDRESSIPROJlCT LOCIITON 23' AC r Tl1n^mr1�r �,^e vIo�� BURS/ BUBIXESS PRONE <br /> Cm S�L� ATE 2JP _ <br /> BOARD DE SUPERVISOR DISTRICT LOCATNIN CODE KEYI KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACULTY ADDRESS ATTENDON:01RCARE OF/MRONALJ <br /> MAIUNGADDRESBCm STATE LP <br /> SIC CODE APN0 COYYENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY ISM FFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINEESNAMETTFNTOW ORCARE OF livo" MAL) <br /> sL <br /> MMuNOADDRESS/Y PHONE — <br /> Cm \L.L STATE LP <br /> ACCOUNT ADDRESS TO SEND FEES ANO CHARGES: OWNERO FACILITYIBUSINESSO THIRD PARTY BILLI <br /> 11 .wr(bYP LYrf 1r'hxoWt.FtN:HFNT: LlLe nnda•I.iEnnl \pplicw.cenifi'IMIIJam tlrfMw✓.IhNnnnr,TlnlANiavLlRon.,rr Rnpmr.iMr l'nrM ivullurbvnrlHlC<IhuL All MNVn F//'. <br /> I'Fs ulf"Aleve\/LYnm.T'nwlAR//ulgo,(it VP•L\arc«i:nnl rill Ill.prnjarl ,ill IH IdilnlwnH:n thrmldin,iAenlifrdaha,aa.Ue.it 1,,,s1:IUNN/:\Y fnr IN,silr. Iat 3arrlik tint all <br /> Inrww:nian Pnnida+l.m tlri,a'plinalan H Dur and corm l:aixl Ucu nil rrSnM1aal:eli.ilira will W IrrRN+nrd i, nd:mrr xid,ul1 npplicaLlr Nsx.IOIOb In('m Yn UNnn YY(F Cum>nndhn <br /> b.Moanaawl NI Uf:anJlar F,IN'R,l Lax.awl REOrI.sTDSs. .\.dNmld.•oiDlnl/brnrr,llpanrn:n.lnlu:ri;FA.IXUIL nr Rnp....We Alm fnr Ile lrcajn'I Iuraled ulxne uwlrr lrtitil,Ailr m1d. .,l <br /> mlM1nrw'hi,rdaaer aC:an mW WI re dl'rrixuL..nuA a,Tmr vn.naxnmeul:nv+.min 4.1' "ian n.SFY IU YVI IY 1 m aY I'.]\11(11]\II YI a Ib'II m UFP........ .....m a.it H u.aiWM1lr <br /> .....I:nUH.:nne linx•it mpray idnlmnu•ar nn r,,r..nu....... 111 r1 1 <br /> APP1Jc,iw NAYE(PLFASEPRINr) •/E'rL -/U^Q t I)/ i!-r 12-- SIONATUR6 S—yJ(` (r�' 1,,1- <br /> TIRE Cto S Q.,.•gli_�.. .f�s � WT�}� TAX ID, <br /> APPROYEDBY DATE _ACWUNTING OFFICE PROGmSINa COMNETED BY _ DATE <_ <br /> 9REMTWT011 AMOUNT PAID DgTE OF PAYMENT p PAYMENT TYPE RECEIPTS CHECKN RECEIVED BY WORK PLANPE <br />