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San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> IE- 1. SITE MITIGATION&LOP <br /> DE <br /> 8HADAMVQB F-110-4EONLY OWNER IDN CASE# UNIT IV V <br /> OWNER FILE;COMPLETETHEFOLLOW/NOPROPERTY OWN ERR 1NFORMAr/ON: CHECH/FOWNER CURRENTLYONAILEwimEHD <br /> t <br /> 'PROPERTY OWNER NAME 1� �( L 4 ;/ ! <br /> First MI Last PHONE NUMBER ✓ <br /> SUSINESSNAME E•MAILADDREss <br /> �virrn�-,r �C�- �-t-eL Wlativ�ae-tuf,� t:urf�v'-i , el <br /> OWrier Home Address <br /> City STATEC 14 ZIP S-3 <br /> Owner Mailing Addrops <br /> 5(jL VIA.e_ <br /> MailingAcidressCity state Zip <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION^ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACIUTYIDN INV# ACCOUNT ID PRa%RO# ria a o� ,�LL t (c 'E� R n o di"`� I►� ,s <br /> 22 �T.P� , r•1, �.I 7i !.- t7�iY c+ <br /> FACiurvFILE COMPLETE THEFOLLOWINa 9USINESS/FACILITY/SITE1NFoRMA7/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 a NEW TYPE of regulated Business? YES ❑ No [I'BUSINESSIFACILITY/SFTE NAME O!"✓V��./- 4 `� � pQ. ti!e.-t <br /> SRE AOORESB �/_ I SUREN BUSINESS PHONE <br /> t.P <br /> CITY ..,..- STl/'AVE Zip <br /> Gt- <br /> BOARD OF SUPERVISOR DiOnlar LOCATIONCdDE KEW KEY2 <br /> Mailing Address WDIFFERENT hvm,Fee/IityAaidress Attention:orCare Of(optional) <br /> 70 Sox 7,c' <br /> Mailing Address City � STATE ZIP L A �S 379 <br /> SIC CooE APN# COMMENT: <br /> THmi).P,ARTY'®iLLINO INFOI Complete if Billing Party Is different from Property Owner or Facility Operator(dentifledabove. <br /> BUSINESS NAME C Attention:orCare Of(optlonaq <br /> Mailing Address l PHONE 17 L-c1y�,.�. Pet-�✓v� S U i�'n � Zv S <br /> :CITYSTATE ZI <br /> Mc7cL2 s t o C.t4- cy 35/ <br /> AmQuAirAnnREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLUM AND CbmWklvice A6s:x6 isiCMENT: I,the undersigned Applicant,certify that 1 am the Owner,Operator,orAuthortud Agent or this Business,and I acknowledge that oil PBOfIrFEFs, <br /> PEA;ttrtEc,ErvFottcEAraxrCnARGEsan&orlfouetrCruaces associated wish this operation will be billed tome at.the address IdenNRed above As the AccotmrAomt for this site.1 abo certify that all <br /> Information provided on this application is true and correct;and that all regulated activities Avill be perrormed In accordance wish all applicable SAN JOAQUIN COUNW Ordinance.Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As list undersigned owner,operator,or agent of the property located at We above faclllry/site address,I hereby authorize the release or <br /> any and All results and environmental assessment Information to SAN JOAOUiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as coon as It is available and at The some time It is <br /> provided io me of my representative. <br /> APPUCANTNAME(PLEASE PRINT) v SIGNATURE C'G <br /> Tax I D# <br /> TITLE <br /> oeGU✓�r LL <br /> A roved By Dots AeeounUngOMooProceseingCompletadBy Date <br /> p 4-y....;.. <br /> BRE MITIGATION AMOUNT PAID GATE OF PAYMENT PAYMENT TYPE RECEIPTN CHECK RECEIVED BY 1,k110R-.-P� <br />