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J0 0 <br /> San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION EEMFR" GREEN FORM <br /> a0/2otl SITE MITIGATION& LOP <br /> 1 8 EHD O OWNER IDM 1�]3 � ��W� DgEE#�Il M <br /> UNIT IV <br /> I 1 l <br /> OWNER FILE:CGMPLErErNEFOLL0W1NGPROPERTY OWNER INFOR/IManGN cwEDN,FowNEacuenEwrerown�w,mEHD � <br /> PROPERTY OWNER NAME/ ��.�T/la/ .Sr. w )�qp-7799 <br /> First MI Last PHONENUMSFA <br /> BUSINE39NAME EMAILADDREE I <br /> Owner Home Address <br /> city STATE zip <br /> Owner Mailing Address <br /> Pu /�De S3f9 <br /> Mailing Addreanc ty Sfoc%/a, sarc'A zip 9' <br /> CORPORATION❑// INDIVIDUAL❑ PARTNERSHIP El FEDAGENCY❑ OTHER❑ <br /> SITE MITIGATION Lr ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLNWUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP_ <br /> FACILITY 10 INV# ACCOUNT ID P RO# Asshamso EMPLOYEE LEADAeENDY:EHD_RWQCB,'Z DTBC_EPA_ <br /> 49-7 _ <br /> FACILITY FILE COMPLETE TNEFOLLOW/NGBUSINESS IFACILITY ISITE Iwonfif ww <br /> IS this a NEW Business LOCATION not preVIOUSly regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO IJ <br /> Is this an EXISTING Business LOCATION but NEW TYPE of regulated Business? YES ❑ No [.]� <br /> BUSINEBetFACIOTY/SITE NAME <br /> i /a5.rci loan •e/ /Jcv� <br /> SITEADOREW SUITE# BUSINESS PHONE <br /> /0o,Op,p <br /> CIN <br /> STATE zip <br /> Sftl�lrlo., �4 9S2/S <br /> BOARD OF SUPERVISORDI6ROCT LOCATION CODE HEYT HEY2 <br /> Melling Address 9DIFFEREAITrmm FaclWAdamss Attention:or Care Of(optionsell <br /> Malling Address City STATE zip <br /> SIO CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFaculty Operator identified above. <br /> Busis ess NAME � Attention:crCare Of(optmang <br /> soave.. � Zn�. <br /> Mailing Address PHONE l7a�27a—y�0 <br /> 9"151A to <br /> CITY STATE ZIP <br /> CA S <br /> A 4pp@E89 for fees and charges OWNER FAcll- YIBOSINESS THIRD PARTY BILLING laaaaal <br /> BILLING ANDC PLIA ALTOrOWLEDGa ENT: I,the undersigned Applicant,certify that 1 at the Owner,Operator,ar Aurbodred Agerrt of this Bmbass,and I acknowledge that all PeRAUr Fees, <br /> PENALTIES,FNFORc1O'F.NT C'iRGFS and/or aoUnr CHARGEE associated with this operalion will be bitted to me at the address identified above as Inc Ar.MUNTADDaett far this site. 1 also certify that <br /> all information provided on this upplicodon Is true and correet;.,Id that all regulated aegvllles will be performed In accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes andler <br /> S:nulards and SPATE andlor FEDERAL Laws and Regulations. As the undersigned owner,operator.or agent or the property ifinfed at the above facilitylsite address,l hereby authorize the release of <br /> any oral all results and anlronmental ossessmenl information to SAN JOAQLIN COUNTY ENVIRONMENTAL HEALTH DF.PARTAIENT as soon as it is available and at the same lime it is <br /> provided to me or my representative / <br /> APPLICANT NAME(PLEASE PRINT) A" SIGNATURE ,✓/t}/�T�� <br /> TAX ID# <br /> TITLE �4 Ay� so,es+f•.t� 77-0&L= <br /> APP.dB f Dela <br /> I <br /> Accounting OfRca Processing Completed By Dow <br /> SITEMITIGATION AMOUNT PAID DATEOF PAYMENT PAYMENTTYPE REOEIPT# CHEGH# RECEIVEDBY WO KP 4PLE� <br /> FEE 5 <br />