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SAN JOIN COUNTY ENVIRONMENTAL HEALTH DE!r2TMENT APR 1 2015 <br /> GREENFORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" ENVIRONMENTA <br /> SITElARAMI <br /> SHADFDMEASIOREHbt FONIY ONNERIDN rp <br /> 000c)zog59 CASFH V NIT <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: _rFiEffln wnrftls END <br /> PAWERNOWNERNAM[ <br /> 0a5) (p-44 -gyoo <br /> -F IT MI FAST PNONENUMItR <br /> BUSINESS NAME Q.Y1Q✓t E•MNC ODRESS <br /> /v.wh1 Pro uiteS <br /> P-4-la Qe L u r4*12> Lovt� ( LL lY,common dgn0. @Yeynok�salzdbrbWn.Co <br /> OWNER HOMFADOREST <br /> Cm STATE ZIP <br /> OWNFRMAEUNGAObRESS <br /> 12LOO COncorA ave- E� -AC)CQ <br /> MAIuwmoRFSscm SYATE Zn <br /> ConcorG� C1, <br /> o ccourcamemm ❑INDIVIDUAL ❑PARTNERSHIP ❑GONFmmm AGENR ❑RESPONSIBD.PAMY EQ OEHEP <br /> SITE MITIGATION—ENVIRONMENTAL ASSESSMENT—VOLUNTARY CLEANUP WATER QUALITY_NW PIPELINE INVESTIGATION_LOP_ <br /> FaouRlOq IHYq ARAumrID pqq/pQN AfsIGNEo EMPLOYEE s luu ACEDY EH RWQCB DTSC EPA <br /> riv-0 Rkoo�l96o YRt,S'�oo�8 00044 <br /> FACILITY FILE:COMPLETE BUSfNESS/SITE/PROTE 'INFORMATION: <br /> IS THISA NEW PROI ECT LOCATION NOT PREVIOUSLY REGULATED 6Y THE ENVIRONMfNrAL HEALTH DEPARTMEW? YES El NO Q� <br /> 15 THIS AN FRISTING PROI ECT LOCATION,RIIT A NEW SCOPE OF WORK? YES 2 NO ❑ <br /> BUSINESS FADDIY$rtE PROIFR NAME <br /> 1 n - ra <br /> SETEADDRESt PRONCTLOCKRON I SURE BOSI SPHRJE <br /> C l o2Cq �5W-q <br /> Cm y STATE ZIP <br /> BOARDOFSuP[RvLLDRDWRIR LacnncYCoen KRI KEY2 <br /> MANNA ADDRESS,If OINEREHf FROM FREPMADnAGS Anvinot:ORCARe O{oPn " <br /> sob 6- LOLLI�-J­p VANe <br /> MMurvaAoDNSSEm STATE 21P <br /> c� a <br /> SICCWS pPNq CwRo m <br /> THIRD PARTY BILLING IN11101 COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENRFIEDABOVE. <br /> BUSINESSNAME ATTmaaoaCMFQI nPb <br /> l <br /> MAruNa Ammus PHONE <br /> �cx� �. t' Ike. acxf-gs8 a�� <br /> Cm 1 � C RArz ZIP <br /> ACUUNTITADDRESSTOSENDFUSArm CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING <br /> FILLING AAO COMPLIANCE.A,rN LEbOMENT: I,the undersigned Applicant,certify that[.am the Owner,Opemfor,rDNAorltedAgent,,or Responsible Faro-and E acknowledge Ilial allPmErrPEET, <br /> ftw.rrKt,F.vrOF[CEVFvrCtGRGFs andforllo atErCIMIN(XV associated nith this project pill be billed 10 meat the addrm IdentlRed above as IheACmG rADDx for ibis site. I also certify that all <br /> Infammtion provided on this application Is true and correct;and that all regulateil nclhilies hill be performed in accordance pith at applicable STN JOAQUIN C01w1 *ORDINAN'CFE�COnTs andlor <br /> STANUARUS and STATE RnIIfor FEDERAL Lana End REGCR VUO\S. As flit undersigned Owner,Operator,.In11101 EeatAgent,,or Responsibla Pnry for the pmj"l located Rbove order facuETArt,dd_re&s I <br /> hereby authorize the release of any and all results,reports,and other environmental assessment Information to SAN JOAQUIN C Ino'CywROcltmTAWIFALTNDEPARTP .RRSMS4`g(B.(,.yH(/1{al r <br /> and at list same done It is pro" to ase or my represealos'e, �j RC1/ <br /> APPIIGNTNAem(Pums ifor -2w.�)�I 0 1 SIG URE <br /> Trt¢ ,I ,-e 7-.1 I J Ir /,i fiS^A FLLfJIA TA%IDq <br /> ,4/T-'i` FV—/ �,i 4r , �' FF4v'`L'< o— y E/LRrO/q�e,� <br /> AYRa1FD aY DAIE Af6UN11NGOEmRD0.a(¢5n16(OMMRm BY DATE 'vT <br /> $R[MRIOAlION FEF: AM1tOVMPNO DAIEOf PAYM[M PAYMEMTYPF PERIPTN Cnous# RECEIVED BY WORKPIANPE <br /> e (p 5U _ '�(o�-p - µle+ �S ✓ 3?�-fl 1� ��,�'� . '' <br />