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0 0 <br /> San Joaquin County Environmental Health Department <br /> DATE O 1 111 I PR6 11 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION &LOP <br /> SmADEp ARgAs Fog EHOueE ONLY OYaeato# CASE UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOW/NG PROPERTY OWNER INFORmilinow Cxeofra OWNER CHRaexrcrONFILEmm EHDE] <br /> PROPEnivOMERNAME dQy ) 9 Q1 <br /> First MI Last PHONE NUMeaI <br /> BUSINESS NAME EIMILAOORESS <br /> C. �kiaH t c [Q.LI <br /> Owner Home Add.;; <br /> N•CI NVActo � knom <br /> City STATE LP <br /> co <br /> 9 9 <br /> Owner Mailing Address <br /> Melling Address City stale zip <br /> CORPORATION❑ INDMNAL❑ PARTNERSHIPFED ACESCY❑ OTHER® <br /> SITE MITIGATION_ENvIRONMENTAL AslignmENT VOLUNTARY CLEANUP_WATER QUALITY_NW PIPELINE INVESTIGATION_LOP_ <br /> FAOILRY IDN INYN Accouw lDcc PRMRON AMIGNEDEMPLOYEE LEAD AGENCY:END_RWQCB_DTSC EPA <br /> �O <br /> FACILITYFILE COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an Exi"NG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> Bus memHeActutre/Sm NAME ,ON <br /> I �o '�lo a do d ✓ ✓� <br /> 811E AGGRESS I 9UREN BDNNESS PNDNE CGP • 401 br.'t1MM <br /> 6 r)$L <br /> Cm• STATE LP <br /> Stick v+ CIA9 Rs2ob <br /> BOARD OF SWERVIeDN DIeralOr LocxnotaCops KESS KEr2 <br /> Me1I11g Address heD/FFERENTIrofrr FMO114 Address Attention:orCere Of(opf ions <br /> Melling Address City STATE ZIP <br /> SICCOM APNM Itr9'0;O-05t1 .Qip COMMENT: <br /> Itdl.o 0-13 IIfI-bap-I <br /> THuto PARTY BILLING INFO: Complete/f Billing Party is different from Property Owner orFacllity Operator identified above. <br /> BU9WE99 NAME r .t eNV1J Attentlon:orCere Of(ephrona/l) Jq• <br /> Meiling Addreas <br /> PHONE <br /> l9 6 e r It JOG 510. X693, (a o� <br /> Core s Zr 99(Al a <br /> ACCCf/NZAOOBE9B for fees and charges OWNER FACiLiTylBUSINES9 THIRD PARTY BILLING <br /> BILLING AND CDM A K enT; 1,the undevlgned AppdcenL certify tbt 1 am the Owner,Opnnrw,or AUWwlud Agenf of Mia Sminm, <br /> ---JTaeMawle IV that all PERmfr FE6, <br /> P£NALI'/EE,ENFGNC£me"CHANGES and/or HOUNYCHARCES associated with the operation will be baled to meat the address identified above m the AL'LV(MfADDR£SS for thissae. 1 abo certify that <br /> all information provided on the application is Nur and correct;aad that all regulated acNvidn will be performed in accordance with.3 apptioble SAH JOAQUIN COUNTY Ordinanre Codes andlor <br /> Syvdards and STATE and/or FYoflut Laws anJ Reguledons.As the undersigned owner,operator,or agent of the property loeayd at Mesh...fnedity/dy add.,I hereby S.M.rac the releme of <br /> ..,.ad all resWn and eaviro.menyl aaamsmcnt informed..to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTh Was snna NII is ay.d.ble and at Hosanna time it is <br /> provided an me or my repmentaHve. <br /> APPLICANT NAME(PLEASE PRIM) r in Ict1 I�l r� 11) 91aHAttN1E �A�,y <br /> / <br /> TAX ID# <br /> TITLE e ec�G 1 <br /> Ap b eY Day Accau Orta Precool Can alae B Dab <br /> SITEMOIOATION AMOUNTPAID DATE O�FjP YMEM PAYMENTTYPE REDEIPTN CHEGKKNE RECEIVIVEDBY WORK PUN PE <br /> FEE:y Z — l�[ I n � K (yT{':Ye71/ �1�. <br />