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San Joaquin County Public Health Services Environmental Health Division <br /> GREEN FORM <br /> DATE 9/ 10/01 MASTER FILE RECORD INFORMATION "MFR" <br /> SHADED AREAS.FO(L€HDU SE ONLY �,iM� �' UNIT IV <br /> OWNER ID# I I CASE# I ` <br /> OWNER FILE <br /> COMPLETETHEFOLLOW/NG PROPERTY OWNER INFORMATION: CHEcK1F OWNER CURRENTLYONF/LEwlrHEHD <br /> PROPERTY F PHONE <br /> OWNER NAME M&P Investments — ot� �, A <br /> Fust Mt laet <br /> BUSINESS NAME M&P Investments Soc SEC/TAX ID# <br /> Owner Home Address 1021 Black Diamond jVay DRIVER'S LICENSE# N/A <br /> City <br /> Lodi STATE CA z, 95240 <br /> Owner Mailing Address 1021 Black Diamond iVay, Lodi , CA 95240 <br /> Mailing Address City Lodi State C A T"P 95240 <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP'a FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID# I ACCOUNT ID# INV# <br /> COMPLETE THEFOLLOW/NG BUSINESS / FACILITY/ SITE INFORMATION: <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business 7 YES ❑ No <br /> H0tNMWK4, JLL4V/SITENAME Former Busy Bee Laundry <br /> SITE ADDRESS 40 N . Main Street SUITE# BUSINESS PHONE <br /> CITY STATE ZIP <br /> Lodi i,1 <br /> BOARD OF SUPERVISOR ( _ LOCATION CODE KEY1 „ , KEYZ _ <br /> Mailing Address ifDIFFERENTirom Facility Address Attention:or Care Of(optional) <br /> Mailing Addrt:.;s City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Completeif Billing Party is different frofn Property Owner or Facility Operator identifiedabove. <br /> BUSINESS NAMEAttention:or Care Of (optional) <br /> E2C Remediation, 1,1J' Attention: Goalwin <br /> [Mailing Address 5300 Noodmere Dr . , Ste . 105 PHONT661) 831-6906 <br /> Bakersfield 93313 <br /> CITY STATECA ZIP <br /> AOCOLINrAQQREE-5 for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND C ONIPLIANcE ACKNOWLEDGMENT: 1,file undersigned Applicant,certify that I alit the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all <br /> PERDIIT FEF:N',PENALTIEN',ENF'oRCE.41ENT 01ARGES and/or 1l0(IRLI'C1L4R(:EV associated with(his operation will be billed to me at(he address identified above as the:t('Col/NTAI»)KECY <br /> for this site. 1 also certify that all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN <br /> JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDER4I.Law's and Regulations. As(Ile undersigned owner,operator,or agent of the property located at the <br /> above facility/site address, I hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DIVISION as soon as it is available and at the same time it is provided to nle or my representative. ^ <br /> PLEASE PRINT , /� <br /> APPLICANT NAME [lU V l d Mustin SIGNATURE, C///1�/// <br /> TITLE( ene I Partner MCIP Investments DRIVER'S LICENSE#v nD2S,s371 <br /> r a� /PRf1Th(:nPY RFOIIIRFDI�(� <br /> Approved ByDate Accounting Office Processing Completed Date <br />