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SAN J0910IN COUNTY ENVIRONMENTAL HEALTH ARTMENT <br /> DATE S / `l MASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> _ SITE MITIGATION R LOP <br /> &NQEQAREAO—FCR EHO,M <br /> -QKT OWNER IDP CABEI UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: fiNELYT/FOMNETPAr CuRREMLrrAVRLE NTTH END <br /> PROPFmr OWNERNAME SPP �01 -/ - 1 ) lO J g J $ ` O$Cd <br /> FAST MI LAST PHONE NUMBER <br /> BUHNEas NAVE / wA ,l� E-HAILADDREBB /; p <br /> 0C #er Q✓e AA 6, loc. /Tf n : S4trr SL rh S C� Rf tIrS6C'l.S,l•nQ) <br /> OWNER HOME ADDRESS <br /> Cm 1A <br /> /` BrATE Lv <br /> OWNER MADINO ADDREw �q7� P4we1/ Sd{1Ed */(/ <br /> SWUNG ADDRESS Cm r r 8rATe/ 71Pq <br /> �/ f�N40i .[Cil Q /r 6 <br /> j COppORATRIN ❑INQNIDUAL ❑PARTNERSHIP ❑GOVERNMENT ADEN" ❑REsisomBLE PAR1T ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP WATER QUALITY_._._HW PIPELINE INVESTIGATION _LOP _. <br /> FADII.m IDI INv1 AccouNr lD PRNROI ASSIGNED EgMPgLOYEE C LEAD AOENOY:EHD_RWOCB_DTSC_EPA <br /> FACILITY FILE:COMPLETE BUSINESS I SITEJ PROJECT INFORMATION: d <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIDUBLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES I,:{ NO ❑ <br /> IS THIS AN E%ISONO PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ NO a <br /> BUBIMI:BBIFAGIITYBRERRWECTNAIS A(M j gt 'd <br /> SITE AODnea1 I PROJECT LocarcI jFSLIDE• BUSINESS PHONE <br /> 7�6 yaf�' /�I�nl.r �K n Ane _ <br /> Cm / STATE LP <br /> StOC/'C ^L^ C-,+ <br /> BOMB OF$UPERVIBOR DIBTRIOT LOCATION CODE KEYi KEY2 <br /> MAIUND ADDRESS,IF DIFFERENT FROM FACILITY ADOMEea ATTENTmN:OTCARE OF(OPTIONAL) <br /> MALINOADDREaBCm y STATE LP <br /> I �J ZIi O'O LI <br /> 11 SICCOce3-HHo_ol CanENr: <br /> -IH 3 -YHo -bZ <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAMEATTENrroN:ORCARE OF(OPfaOYAL) <br /> MAuNQADDREee <br /> 3 �7$' �(�[;r � i1-Yf, SL��e ion ,S' 51-073 <br /> CmSTATE LP <br /> PicQsan � Cf f .2 <br /> ACCOUNTADDRM TO SEND FEES AND CHARGES: OWNER❑ FACILTTY/BUSINESS❑ THIRD PARTY BIWNG;ir <br /> BN,LtKG AND C ACKNOWLEDGMENT: L the and r igned Applicant,certify that Istel ON Owner,OPerabr,AWhorrrdAgenl,ar Resporrsfbk Petry And 1 acknowledge that all PEAM FEES, <br /> PE ALnEs,ENFORGENEA'FCNA w and/or NQunr CHARGES sa elated wind this projat will be billed W me at the addrea idenfirl abosx m the AccounTADQREss far thle deo 1 also certify that all <br /> information provided on this epplicati-n is Ute and carnet;and that all regulated aelivides will be performed in accordance with all applicable SM JOAOUDI COUNTY ORDINANCE CODEN and/or <br /> SrA ARm andSTATE and/or FEDERAL laws and RECULATTONS As the undersigned Owner,Operdor,Audarited Agent,or Respensdik Parry for the project bove under facility/sale addnes%I <br /> hereby authorise the release of any and all results,report%and other environmental assessment information to SM JOAQUIN CQQNTY ENM tSNrAL HEAL DEFARTMENT M soon aS it is available <br /> and at the same time it is provided to me or my representative. I <br /> APPLICANT NAME(PLEASE PRINT) Q� Cn ( �a— SIONAIIRE <br /> f TAKID/ T- W695y <br /> TffLE P�nJ IaC� 5(sIQU�IST <br /> FAP..BY OATS ACGOIaRWn D6f1aE PROCERDMO CaYPIETEn BY NATE <br /> Sm MITIOATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPTI CNEOMI RECENED BY WORKPLAN PE <br /> FEE:; ��; 3i� Szi iii E�cer 1 0ZL/?o63821 F cr ��/SU <br />