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'I <br /> I. <br /> San Joaquin County Environmental Health Department <br /> DATE 1112112012MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED AREASMe END USE ONLY OWNER ID# : : CASE # � Roa GGZ31 UNIT IV <br /> I I <br /> OWNER FILE : COMPLETE THEFOLLOW/NG PROPERTY OWNER A(FoRmATiow C ECK/r OWNER CuaaENTLYOYFrzewt H EHO F-1 ' <br /> PROPERVOWNERNAME Nin ie � ade ) a93-rale <br /> First AN Last PHONENUMBER <br /> 1 <br /> BUSINESSNAME EMAILADDRESS <br /> No uisness a Site mine no. rom <br /> Owner Home Address <br /> ,OaT Dldwood Court - <br /> city San Jose STATE ZIP A <br /> 95148 <br /> Owner knelling Address <br /> same as above <br /> Mailing Address City State - Zip <br /> f <br /> CORPORATION ❑ INDIVIDUALE) PARTNERSHIP ❑ FEDAGENCY ❑ OTHER ❑ i <br /> SITE MITIGATION _ IS WRONMENTAL ASSESSMENT _ VOLUNTARY CLEANUP WATER QUALITY _ HWPIPELINE INVESTIGATION LOP <br /> FACILITY ID # I <br /> NoACCOUNT AccouNr lD PR #/ RO# ASSIGNS EMPLOYEE LEAD AGENCY: EHD_RWQCB D7SC_ EPA l <br /> N� 3Rts /99 < fS9 l <br /> FACILITYFILE COMPLETE THEFOLLOWING BUSINESS I FACILITY I SITE /NFORMAT/ON: - <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION but NEW TYPE DT regulated Business? YES ❑ No i] } <br /> BUSINESS/fADILITY/SITE NAME Nceillin heal Estate Investment - <br /> I <br /> SITEADDRESS SURE# BUSINESSPHONE f <br /> - South2154 ora o Street [ <br /> Cltt Stockton CAT211 os F <br /> i <br /> BOARD OF SUPERVISOR DISTRICT LOCATIONCODE Kul KEY2 <br /> Mailing Address AcOIFFERENTIrom Faci%tyAdd ess Attention: orCare Of loptiorari { <br /> 087 oldwood Cour ]- <br /> I <br /> Mailing Address City STATE ZIP j <br /> - CA 95liR <br /> SIC CODE n APN # COMMENT: �( <br /> /Iota <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFacility Operator identified above. I <br /> BUSINESSNAME Attention: orCare Of taptlora/l ? <br /> Mailing Address PHONE <br /> CIT! STATE ZIP <br /> ACCOUNTAOOREas for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING } <br /> Bice v COn CE ACK : I, the undersigned Applicant, certify that I am the Dinner, Operator, or Audior'zed Ageutof this Business, and I acknowledge that all PmiffFses, <br /> ,v <br /> P£ es`F.RFORCE.IDRAfCup and/or 11ovely CRARGFs associated with []its operation will he billed tome at the address identified above as the AcCraveurfamm.xT for this site. lalrnecrtifythat <br /> all information provided on this application is true and correct; and that all regulated activities will he performed in accordance with all applicable SAN JOAQUIN COUNIT Ordinance Codes and/or <br /> Standmrdsand STATE and/or f7puERAC Lows and Regulations. As (fie undersigned owner, operator, or agent of the properly located at the above facility/site address, I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQIBN COINTY ENVIRO"IENTAL HEALTH DEPARTMENT as soon as It Is available and at the sonic dine it is <br /> provided to me or my representative. /;V <br /> APPLICANT NAME (PLEASE PRINT) Nin Le SIGNATURE� �`; -SGC-� <br /> TITLE TAX ID # <br /> ���r, b T 3s3 � � 67 � ST/ y <br /> Approved By Dale Accounting Ones Processing Completed By Date f Ids <br /> STEMITIGATION AMOUNT PAIDDATEOFPAYMENT PAYMENTTYPE RECEIPT # - CHECK # RECEIVED BY WORk PLAN PjF. <br /> FEES - ✓/� <br />