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San Jo."..iin County Environmental Health L,,,�artment <br /> DATE MASTER FILE RECORD INFORMATION"M. FR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADED AREA9 FOR EHD un ONLY OWNER 100 CASE 0 -5�b 63 1$ UNIT I �+ <br /> 6 <br /> CZNX312 PILL'':Cos aPLETE MEFOLLOWNG PROPERTY OWNER Iwomf. yam CHEcmiF OWNER av-RREArn Y aN RLEwmv EM <br /> PROPERTYOWNERNA►aE <br /> First M/ Last PHONE NumBER <br /> BU9IttE99 NAMEG D�VF"�v/E G� .9fG�S t�G G E.MAILADDREss <br /> Owner Home Address <br /> City STATE LP <br /> Owner f:Jailirrg Address <br /> k7ft Addr—Clty 56 <br /> CORPORATION E5 INOMDUAL❑ PARTNERSHIP❑ FED AoENcY❑ OTHER❑ <br /> Cm MmeATION_I2Nvt-ox�- fAL AW===ar vewxrarnr CLrnNua_VATm Qua m_H0 Pip==ImmeTwaT,oH_LOP <br /> FACIUTY100 INV# AccouNTID ROD ASSIGNED EMPLOYEE LEAoAoENcY:EHO—'A-<'-RWQCB_DTSC_EPA_ <br /> FACILITY FILM CwPLETB rHEFoLLowiNG BUSINESS/FACILITY/SITE/NFommriom <br /> Is this a NEW Buskiess LOCATION rat previously regulated by the ENwRON--ENTAL HEALTH DEPARTMENT? YES ❑ No:9 <br /> Is this an DUSTING Business LOCATION but a NEW TYPE of <br /> regulated Business? YES El r <br /> BU3INESS/FACIL(Tl/817E NAME 76 CpOK <br /> Zxulv, G 1/ <br /> 1 ?2- <br /> BrtEAooREs9 I k1 <br /> 8u1TEs BUSINESS PHONE <br /> V <br /> 03 wR75 G G G VP. <br /> CITY ATE P r-� <br /> /BOAROG K o A.,- <br /> BOARD <br /> D OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> LICA gAddress9ZI FFERiea'IfrfmnFacA*Addresa Attentan:arCaroOfi ) <br /> rate Address Gly STATE ZIP A A <br /> BIC CODE APN 9( a �2�Z���f 6 COMMENT: sits � _j{kg P-M— T. � <br /> THIRD PAnTY DILUNG INFO: Complete if Billing Party is different from Property owner orFacility Operator idenffiedabove. V � <br /> BUSINESS NAMESDG �' At ar G a� / 'G <br /> r Address <br /> 25 vP G J !M;? 5/7- 7 a <br /> CmM �T STATE ZIP <br /> 4� 15"F <br /> for face end charges OWNER FACILITY/BUSINESS RD ARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and 1 acimowledge that all PERI UT FBE.V <br /> PENAL77ES,ENFORCEMFNFCHARGEs and/or HOURLYCHARCEs associated with this operation will be billed tome at the address identified above as the ACCOUNTADDRF-V 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 JOAQUIN COUNTY Ordinance 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 time it is <br /> provided to me or my representative <br /> APPLICANT MWE(PLEASE PRINT AM/�� G��'1/j��.r/ SIGNATURE.. <br /> TITLE 5E;y10 R PRgZ �-r 14A4/AOR TAX to 0 '16-03 f 9 to go' <br /> App--d By Ded <br /> ot. Aoeoirng Office P Completod ByDate <br /> SITE MITIGATION s�A�lMOUNT PAID DJj TETE OF PAYMENT PAYMENT TYPE RECEIPT S CHECK RECEIVED BY WORK PLAN PE <br /> FEE:({ `f (��i 7f 9` K <br />