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! • <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> ` MASTER FILE RECORD INFORMATION"MFRS' GREEN FORM <br /> /Z— <br /> /0 / y SITE MITIGATION&LOP <br /> 4 97z� `'OWNFJIIBM /�no, /lCMEIS/(OOG9722 UNIT IV <br /> :COMPLETE PROPERTY <br /> tOWNER/RESPONSIBLE PARTY INFORMATION: CHEtWWO NERMCuRxEN YONReettrne END <br /> NI <br /> /i PRoectmowwERNE SPP 1 P1,`/ - � Yrrt ( ) SJOJ eJ <br /> Fwsr M, LA. PNoNE NuMsER <br /> BUSINESS NAME ErVAIL ADoRESS <br /> Q ( I lnr L <br /> OWNER HOMEADDR[60 r <br /> ,�I A- <br /> Cm .VIS- STATE LP <br /> OMER MAILING ADORESP lqt ) , Pel, -�I(/ <br /> DAAILINOADURECSCm IF V4STATE, <br /> Ly CONPOMTNIN ❑INDNrIOUAL ❑PAIfTNERSHIP ❑GOYERNtlENTAGENCY ❑RESpumilllu PAm ❑QIryER <br /> SITE MITIGATION X ENVIRONMENTAL A53E83MENT_VOLU14TARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION—top_ <br /> FAOILITYIO/- 277NY�JoOGUMIrld PRWROS MSIGNED EMPLOYEE LEAD AOENOY:EHD_RWOCB_DTBC_EPA_ <br /> IWC) <br /> FACILITY FILE:COMPLETE E BUSINESS'7�1I Sn'd PROJECT INFORMATION: l <br /> ISTHIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENNRDNUENTAL HEALTH DEPARTKENT? YW Q No ❑ <br /> IS THIS AN DGBTINO PROJECT LOCATION,BUT A NEW SCOPE OF WORIB? YES ❑ No <br /> BuSuNESS1F=U YISffF1PRDJEeT NAME I! - <br /> INl T 1?(EJ 1 <br /> SRE,haval lipitwECFLoCATION SUITED BUSINESS PHONE <br /> Cm 5- rc 4 <br /> STATE ZIP <br /> C'� 9s�PS <br /> BOARDOFSUPEINISORDISTRICf 01 Lommu CODE Q/ NEVE NEY2 <br /> MARING Awness,IF DIFFERENT FROM FAcnirrY ADDRESS I ATTENTION:mCARE OF(OpTp.Wef <br /> MAIUNG ADDRESS Cm STATE Zip <br /> /:Et" Zso•oY <br /> 81C Coce - - APNI 14 3-HNa-01 COMENr. <br /> I`i 3"-vvo -ate <br /> TNIRO PARTY BILLING INFO:COMPLETE IF BI W NO PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME '}I �t�r I( f I ATTENTION:ORCARE OF(OWDOIWL) <br /> MNUNGADORESS PkONE <br /> 3Y78 K��;r >t e. Serle lam (4��) s1-�373 <br /> Cm STATE ZIP <br /> PlwAn,L fl ( SZ <br /> ACCOUNT ADDRESS TO SEND FEW AND CHARGES: OWNER❑ FACILrry/BUSINESS❑ THIRD PARTY BIWNGK <br /> BILLING AND CON!rI.uNCE AC"OWLEDGNIENTi I,th_wdelsigrod Applrsn4 mrtify ticllv."v Oc Oa•acry Opercar,AUkarired Ager_',or P.cs rsibla Pa vy eldln<Lnaxie.gx lfut oil Per PEES, <br /> PENAmu,ENFORCWN CIGROET and/or HOUW CHARGES of sated with thio pm*t will be billed 0 mal Ne o&f identifird abava m the ACCOUWADDR£SS r.WN dI6 1 also certify that all <br /> information provided on this application is true and correct;and that all regulated activitim will be perror ned in accordance with oil applimhie SAN JOAQUIN COIMfY ORDINANCE CODFs and/or <br /> STAR[) R -d STATE and/or FEDERAL Laws and RECULATIONS As Uwutldemignod Owno Opermar,ANharwdAgeN,or Rerpondb/e Panyfor the project 2d above umkr fttility/site ddre I <br /> hereby au9Nrin the mlmce Jany and all resulix reports,and otler environmental ar .meat ildorraation fa SAN JOA00DI CoUtTY ENvu IE AAL FfEAL DErARTTtEFT m Mn Sa it is gnilabla <br /> adelSha rrrxtimeitLprovided foIce ocmyro'pr^T.sendativ� ( �. <br /> APPLICN.T NPPAE(PLVdEPWINT) / VVLV r`Q� Cp ITti� flIONATORE <br /> TITLE S1^�rSf <br /> TiutiDG 7- Gy6695y ci e — <br /> AprwV®ISY GATE A0.^G.rNTraG D.4lG.E PAOGESSrtG CON£tETIDBY DATE <br /> SITEMMIOATION AHOUNT PAID DATE OF PAYMENT PAYMBfTTYPE REOEIPrP CHECNB RECEIVED BY WORK PIAN PE <br /> FEE:; 3?� i7S s ZI I`� EeceT OZLI�o/� 3B E,cr 9191 (0 <br />