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0 0 <br /> San Joaquin County Environmental Health Department <br /> DATE O I /11 I a6I I MASTER FILE RECORD INFORMATION"MFRrp GREEN FORM <br /> SITE MITIGATION & LOP <br /> 9 EHD O OWNER IDS CABE0 UNIT IV <br /> OWNER FILE:COMPLETETHEFOLLOWING PROPERTYOWNER/NFORMAT/oN.' CHECK F OWNER CURREN TL Y ON FILE WirH EHD� <br /> PROPERT(OWNERNAME .�1 -(267) <br /> / p <br /> AV / \ 19 O) <br /> Firsf AR L Leaf PHONE NUMBER U <br /> BUSINESS NAME .1.. E-MAIL Acasoras <br /> IF[ . C CQ.L1 <br /> Owner Hama Addrese <br /> y N.CIpoloido � Room <br /> City - STATE ZIP <br /> S 9 19 <br /> Owner Melling Address <br /> Mailing Address City state Zip <br /> CORPORATION❑ INDWIDUAL❑ PARTNERSHIP FED ADENOY❑ OTHER® <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT VVOLUNTARY CLEANUP_WATER QUALITY_NW PIPELINE INVESTIGATION_LOP <br /> FAOILm IDR INV# AccouNT ID PRN/RO# geRmNED EMPLOYEE LEAD AaENav:EHD_RWOCB_OTSC EPA_ <br /> FACILITY FILE COMPLETE THEFOLLOWING BUSINESS/FACILITY/SITE/NFORMArlon: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> IS this an EXISTING Business LOCATION but NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESSIFACILmISITE NAME ` 1 <br /> 1 o 'No a1/6 .f 4 t^� CVT '2 L N, 1 <br /> SmAsmaEss I �p BQRE# BUSINESS PHONE CnPI. 44It VI r,1�AP�1 <br /> Cm STATE ZIP <br /> S4ac�C vl 95 09 <br /> BOARDOFSUPERVISDRDISTRIOT LDGITION CODE KEYT KR2 <br /> Melling Adores /fOIFFERENTfrom FICA&ACdreu Attention:orCare Of(optional/ <br /> Melling Address City STATE ZP <br /> SIC CODE APN# 149-0;6-06111A1 <br /> 09-0;6-0511 ;6- COMMENT: <br /> I(4.0 0.13 lIF1-6gV'O'o <br /> TNIRo PARTY BILLING INFO: Complete If Wiling Party Is different tromProperty Owner or Facility Operator identified above. <br /> BUSINESS NAME Cre 6C1- I FAVI Attention:orCaOf(opUonaQ <br /> ql �II <br /> Melling Address PHONE <br /> 19l a ekr'6 'v*tel ;L'4 10C 510. 193, ('700-1 <br /> Cm <br /> ACCODRrAonaEss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: ],the undersigned AppGeenh teflify that]am the OMnery OprrOfOq Or AYIM1OIIZ¢d Agcn1Of this Busi.m,nn nclmnWledge that.11 PFRMIr FEE, <br /> PENAL//ES,ENIVRCEssawl CHARGES and/or NOURLr CRARGFS associated With side operation Wil be billed to an,at the Bddrea identified above m the Accoyor"DREss for thle An. 1 also eadly that <br /> aD infor esfien provided on This appicnfion is nue and carrerh and that as regulated ut viNes will be performed in accordance with an apphc.ble SAN JOAQUIN Comm Ordinance Cada and/or <br /> Standards and STATE and/or FEDERAL laws and Regulations. As the undersigned owner,operator,or agent of the property located at Me above bcifily/sire address,I hereby authorize the release of <br /> any and an resale and environmentnl assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avanabie and at the same time it is <br /> provided to see or my repraenfe6c. ` 1 <br /> APPLICANT NAME(PLEASE PRIW) l/�.t/a IG I t�q III 9roluiuRE <br /> T w�f <br /> TITLEl TAX ID#S > eb'6 )S <br /> Ap roved By Dab Accounting OMca Procanzin Com lafada Data <br /> SITEMil"TION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# REOEIVED BY WORT PLAN PE <br /> FEE:lit <br />