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i • <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE />0 1`1 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> OWNER r� /,1n019 <br /> W _D a 4722 UNIT IV <br /> o�A�__ EH�ONLT /,�I C�uE�SR�G9 X22 <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSI (BLE// PARTY INFORMATION: CffcWWONNExrsCURAENrtrovFNENTTnEND E] <br /> PaorDDY otAmER NAME SPP �P(•� - D+s;he ( )370— °>$" 0$0(/ <br /> FmT MI LA f PNGNE Numiza <br /> BUYNENN ME 1 Ey1NL AO nswit <br /> Gf 'fc.� Q✓e(A LL•t pwT in(. f✓e Sc .rh S (L. of <br /> O"Ut HDPEADDRFIi / <br /> Cm I/T STATE Zip <br /> ONNERMMLINGADDIIEN J I )� p.,el/ <br /> MMLINGADINtm Cm L7 f ,I/e - STATE, TJr?�� <br /> r� ] lA4Qi .�n /rA <br /> Ky CpIPOMTION ❑INDIVIDUAL ❑PAMIUSHIP ❑GovivooEMAGENCY ❑RieuaONEIIIF PMfY ❑DHFR <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FAcIt.m1D8 IN" ACcouuTID PRNIROS ABBIGNED EMPLOYEE LEAD AGENDT:EHD_RWGCB_DTSC_EPA_ <br /> oo4DgR2 �o1679 <br /> FACILITY FILE:COMPLETE BUSINESS/SITEI PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BYTHE ENVIRONMENTAL HEALTH DEPARTMENT? YES LAe No ❑ <br /> IS THIS AN EKIBTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No 5' <br /> BWINEBNFII uT/ISGFIPRPIECTNAME Av1 �egro <br /> I <br /> SITE Atiomom I PROJECT LDGATiom �veSUIfE# SUNEM NPHONE <br /> 7/6 has} ��nLr ., ,,.e <br /> CmSkcC r ^N STATE Lr ._ <br /> {t c-'f 9sa6s <br /> BOARDOFSUPENVIBONDIBTRICT 01 LocATION Cone �j� KEY1 KEY2 <br /> MAKINGADMEM.IF DIFFERENT FROM FAML ADDUSS ATTENmu:weCARE OF(oPaama) <br /> YAWNGADOREN Cm STATE Lr <br /> / �'2so•oY <br /> SIC CODE APNS /4 3-Hyo-ol COMEJIM <br /> 11 H 3 -4,10 -Gz- <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNEROR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUS01 NAME F ATrENrtoH:MCARE OF(OPTMUL) <br /> MMUNGADORMs 3 �(7$' ,A/�; � �✓f, SAt:�P lD(/ P <br /> HDNE <br /> r <br /> Cm STALE LP <br /> At N.ADDREM TO SEND FEES AND CHARGES: OWNER❑ FACILffY/BUSINESS❑ TioHD PARTY BILJNGAr <br /> BILLING AND COHrLIANCE AGKNDw'LEDCMENT: I.de undersigned Applicant,certify that I am HR Owner,Opemaer,,Authork dAgent,or RespmsibL Party and 1 acknowledge that all PERATTTPEES, <br /> P£NALnE,ENFoltceUe CN, u and/or HwnrCi,a Es aeanetaled with this projeet will be billed to meat the address Identified above as the ACCODATADOnE.tt'fn th'e rifle. I also certify that all <br /> information provided on thin application is hwe end eo ti and that all regulated activities will be performed in mco dan a with all applicable SAN JOAOUIN COUNTY OEDR'ANCE CODES and/or <br /> STAMIARDS and STATE and/or FEDERAL Laws and liEcuuTmNS As the undersigned Owner,Opermor,Audariud Ageedor Rerpomibk Party for the pr j l�ve oder fedlity/rile acus n I <br /> hereby authorize the relent of any and AU rrndls,reprAv,and aper emiromrental aaeam nit ildormation W SAN JOAOUN COlgrrY ENM } (ENTAL HEAL DErA0.T111ENT m noonn v it u avaitabk <br /> modal the same time it is provided to me or my represmla&e. <br /> APMJGWTNAJIE(PLFNEPRINT) / VK Qvk Cp l'EFN BIDMATURE <br /> TIME TARIDS T- Gy�s9sv <br /> I Sc(Qtn'�PS'f�' <br /> AlvaDa®Br I OATS ACmMNBOF PflMEFwD COrwLT®BY Can <br /> BRlMmcuvri0'I AMouom Pmo DATEOFIRAT'1MNT PAYMENTTYPE RECEIPTS CHEOKIt RECEIVED BY Wov�PLNIPE}I <br /> Feer 375 5-21-ISI ELC-Cr OZg7o1 .113 ECEC7" - <br />