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San J*in County Environmental Health Dortment <br /> DATEE== MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR END USE ONLY OWNER ION 'SRnaot4,s140 UNIT IV <br /> OWNER FILE:COMPLETE rNEFOLLOWNG PROPERTY OWNER INFORMATION: CWcutF OWNER CIAYREN VONnLEwmf EMD � <br /> PROPEarYOmIRNAME George/Mei Teranishi (Irrevocable Trust) /201 830-6956 <br /> First MI Last PNONE/NUMBER <br /> BUNNESS NAME E MUL Aomen, <br /> Owner Home Address <br /> 1600 W Durham Ferry Road <br /> C <br /> racy SCA zip 95304 <br /> Owner Meiling Address <br /> 1600 W Durham Ferry Road <br /> Melling Address City Stab Zip <br /> Tracy CA 95304 <br /> CORPORATION❑ INDIVIDUAL Fw AoexrEl OTHER❑ <br /> SITE MRIoAT1oNX ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACIurYID# INV# Accoum ID PR Oi AssgNEDENturrim LEADAOBICY:END_RWQCB_ - - <br /> 38-�,U 1 /45-1 <br /> FACILITYFILE COMPLE7ErHEFOLLOwtNGBUSINESS/FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No IM <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No <br /> aUSINessIFacX.nYIStrENAIAE N/A <br /> Sm Aoo,ass 1600 W Durham Ferry Road SuITE# BUSBIESSPHONE <br /> CITY STATE LP <br /> Tracy CA 95304 <br /> BOAIm DP 9uPERUIeaR Dlemlcr LOGTIONCOCE KEY1 KEYY <br /> Melling Address NDIFFERENThemFisclRyAddinesa Attention:orCare Of(optlwTsi <br /> Melling Address City /„ STAT LPG <br /> SICCox APNi COrI®fr: !'✓ <br /> P2.5 <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINEss NAME Attention:orCare Of(olobb s ll <br /> Mailing Address PHONE <br /> Cm STATE ZIP <br /> AGQXMWA02MW for fees and charges OWNER FACILRY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOKLEDCMLN r: 1,the undersigned Applicant,certify that I am the Owner,ODfmrn{or Authorized Agent of this Insimst,and I acknowledge that ag PERMIT F£FS, <br /> PENALTIES,ENFORCEMENT CHARGE'S and/or HOGRLL CH 1116/]associated with this operation will be billed to me at the address identified above as the ACCOUNTAHORFSt 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 Sad STATE and/or FEDERAL Laws and Regulation. As the undersigned owner,operator,or agent of the property located at the above facilitysite 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. `J / <br /> APPLICANT NAME(PLEASE PRINT) Sheldon Teranishi SIGNATURE <br /> TITLE Trustee TAX ID III <br /> Approved By I Date IFA ccoungog Once Processing Completed By Dale <br /> SM MITGATION ANOUNTPdo DATE t>F PAYMENT PAnFMTYPE RECEIPT# CHECK# RECEIVEGBY WONT PIAN PE <br /> FEE: <br /> 3501 <br />