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RE(;WVtL) <br /> San •quin County Environmental Health&partment z <br /> DATE MASTER FILE RECORD INFORMATION` 9PR"' I '�� 4 CEN FORM <br /> ?i SITE NMENT�+'I G�R IV PE MITISE V <br /> eNAOEO AREAS FOR EHD uae QNLY QWNER IDN CASE* ENV <br /> OWNER FILE:COMPLETETHEFOLLOW/NG PROPERTY OWNER/NFORMAT/ON.' CALIF OWNER CuSossrnrowFae MYTH EHD � <br /> PROPERTYQWNERNAME Ul T <br /> First M/ Last PHONE NUMBER <br /> EMAIL ADDRESS <br /> BU51NEMNAME <br /> Owner Home Address <br /> city STATE ZIP <br /> Owner Me..no Address <br /> Malling Address City State Zip <br /> CORPORATION[I INDIVIDUAL❑ PARTNERSHIP El FEGAGENCY❑ OTHER❑/ <br /> SITE MITIGATION_BNYIRONMENTAL ASSESSMENT_VOLUNTARY CI MAMUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP v <br /> FACILITY IDM INV# ACCOUNTID T <br /> PR#IRO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB_DTSC_EPA_ <br /> FACILITYFILE COMPLETE THE FOLLOWING BUSINESS/FACILITY/SITE tNFORMA TION.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No Fer <br /> Is this an EXISTING Business LOCATION buts NEW TYPE Of regulated Business? YES ❑ No E <br /> BWINEaWFACl1 /SITENAME <br /> l! <br /> SREAOORFJI9 SUITE# BD81NE8B PHONE <br /> 2. P v va <br /> Cm STATE ZIP <br /> �C'ov N F ZO <br /> BOAROOFSUPEAVIa RDISINWT LOCATION CODE KEvi KEv2 <br /> Malting Address HDAFFERENT#orn FaSaWAddress Attention:orCare Of fopWne/J <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN0 COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> SUSINess NAME Attention:orCare Of fophlorn l) <br /> (,pr.,�saer..ta.�{✓p,it¢� g oro L La <br /> Mailing Address PHONE <br /> I0(1G L T oYSaz 1® It, 56 '6` K w <br /> STATE ZIP <br /> CIT 0 <br /> A -Orr mvrAooeF..S4 for fees and charges OWNER FACILITY/BUSINESS HI;RDPARTY BILLINGBILLING"D COMPLIANCEACKNCAV.EDenlENr: I,the undersigned Applicant,certify thati am the Owner,Operator,orAudmri.edAgog of this Business,anwlr al nU PERA/iT Fees, <br /> PENALTIES,ENFORC£.VI CHARGES and/or HOURLY CHARGES associated 1Pits,this operation wig be billed to me at the address Identified above as the ACMIINTADDRER$for this site. I also certify that <br /> all information provided on this application Is trite and correct;and that all regulated activities will be performed In accordance with all applicable SANJOAQUIN Conon-v Ordinance Codes and/or <br /> Standards and STATE and/or FEDEn.u.Lows and Regulations. As the undersigned owner,operator,or agent of Use property located at the above factlttyhile address,I hereby authorize file release nl <br /> any and all results..,itensireamenlal assessment information to SAN JOAQUIN COUNTY ENVIRONSIENTAL HEALTH DEPARTMENT as Soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLFABEPRINT) (�to_ t� � p� SIGNATURE ILL,— <br /> �Q <br /> TAX IDI— <br /> TITLE ,�_, _ � <br /> Approved BDeb Amxmauna ORica Pro ceeain,Completed By Dab <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYM"TT TYPE RECEIPT# CHHECCK# RECEIVED BY WORK F IAN P� <br /> FEE: <br />