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San Joaquin County Environmental Health Department <br /> DATE � MASTER FILE RECORD INFORMATION"MFR" GREEN FORM SITE MITIGATION&LOP <br /> SHADED AREAS Fog END USE ONLY OWNER ID# CASE# UNIT IV <br /> OMMERFILE:COMPLETETHEFOLL.OWJNG PROPERTY OWNER/NFORMAT/ON. CHECMJF OWNER CuRREHTLYOMF/LEw7rHEHO E] <br /> PROPERTY OWNER NAME 3-C.rr M aD 0-,C— ( <br /> First M/ Last `PHONE NUMBER <br /> BUSINESS NAME U� OV 0,,,`r P�f f'f7 1 C u�, E-MAIL ADDRES6 <br /> Owner Home Address D o /-d� �S I L C <br /> City `- l I/1' <br /> w 1 STATEC ^ ZIP y �.f/ <br /> s I <br /> Owner Mailing Address t'! <br /> Mailing Address City state Zip <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MRIGATION_ENVa ommmTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION—LOP Y <br /> FACILITY ID# INV# AccouNT iD PR O# 4tZir <br /> - <br /> 3G� .9 tUt- .r.:i..ij• ::r1 S�'.k.r:t;r.'X .r` <. {��'• <br /> FACILITY FILE C0ArPLETE7,HEFOLLOW/NG BUSINESSI FACILITY I SITE 1NFORmwiw : <br /> Is this a NEW Business LocAnoN not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an ExisTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BuaiNEss/FACILRYISRE NAME SrTE ADDRESS C1 <br /> 45 SUITE# BUSINESS PHONE <br /> Cm i s tk1 T-� C r7 ZIP <br /> BOARD OF SUPERvteoft DISTRICT LOCATION COOS 1 7 KEY1 KEY2 <br /> Mailing Address/fD/FFERENTbom FadlityAddress - 1 Attention:orCare Of(optional) <br /> Mailing Address City STATE zip <br /> SIC CODE APN# 2 So�R r� Com: <br /> THIRD PARTY BILLING INFOI Complete if Billing Party is different from Property Owner or Facility Operator Identified above. <br /> BUSINESS NAME PtX EAV;ro) tr- .Tr►L, Attention:orCare of(optional) <br /> 1 <br /> Mailing Address r I Z g <br /> qtma..` PHONE (9 . V� <br /> CITY G/ STATE CA <br /> 7JP S s cv-7o <br /> AccogmrAgagEw for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BiLLINr.AND CompuANcE AcKNOWLE)GMRNT: f,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Badness,ami I acimowledge a PERwr FEFs, <br /> ft tLrtes,ENFOaCE%SVr CHARCEs and/or NOuurCrMitGHs associated with this operation will be billed to me at the address Identified above as the ACCOUNrAunrtsss for rids site.I also certify that an <br /> information provided on this application Is true and correct-,and that all regulated activities will be performed In accordance with an applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent or the property located at the above facnity/site address,I hereby aatlarke the release of <br /> any and all results and environmental assessment iaformation to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPUCANTNAME(PLEASE PRINT) b a✓� Yt)�1-"1*", � SIGNATURE -.eQ4�L <br /> TITLE �!v/CGI' ��l`Y11'{-✓- TAX 10 0 <br /> `l <br /> Approrad By 1 Dela Accounting Office Processing Completod By Date <br /> SITE MITIGATION AMOUNT PAID DATEOFPAYMENIT PAYMENT TYPE RECEIPTS CHECKS RECEIVED 9Y ;WgR'if P}�Iiiln <br /> FEE: <br />