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1 0 <br /> , San J in County Environmental Health Department <br /> DATEMASTER FILE RECORD INFORMATION"MFR" OREENFORM <br /> '" Z SITE MITIGATION&LOP <br /> Sho, DMtFAsfopEHDDeeOK ow"otw# CA*0 UNIT IV <br /> OwmRPILE:ComALE7ErnEAxLowNePROPERTYOWNERAWORml7m vinvar6mmCnwwnranLEmmEFw <br /> Prsort=M OVWAM NAGE Q r <br /> P 2 <br /> First MI Lest PMOME NUI6E1t <br /> BUrtaEse NAstE EpAL Aw"m <br /> TiE 6 )a 1&9-1-- P,14- L t.-r> <br /> owner Home Andrea <br /> d <br /> CAY STATE xe a <br /> cAowner Maillnp Ad&aw <br /> MttWttp 0 Adtlrea CpI' O G''� (i zo <br /> CORPORATION❑ NOWDUA.❑ fsAtTTwmap❑ FmAot cy❑ <br /> an mnwa IDM_ftftV MMfTAL A&&t1&&nefr,&VOU MrMflr CUUMW_MIATwt(QUAMrrr_MW hPRRs UM.TNN"M_LOP <br /> FAcn rrr ro fl N.we Q AttNT ro' Tie a ao s�y <br /> O�J�--. \l�V ,,�zA��y&e','�'�, r <br /> FAcniTYFILE CoAwCETFT/fIEFouowlAPGBUSINESS/FACILITY/SITE/NcoRwin rN.• <br /> Is this a Ww&x*w"LOCATION not Pf'evkmhl feed by the E wMlonMENrAL MEM TH DEPARTMEIM Yee ❑ No �I <br /> Is this an Emma Busirm"LOCATION but a NEwTYPE of rurdatad Mx*waa9 Yi ❑ w <br /> BueetEN*AClrrrt&mNAW r' C. <br /> SmEAootwes &XM# Btt MMOP►Iate <br /> QTY 7-0 C Le--7-0 sTA m <br /> 8omw of SUPt www DI TwM 6 I LOCATION COOS ,0 t «Ett'+ " <br /> Mrlp Ad*ww 0V#M flvr*Vm FAnWA *vmwt Atberrlax acre Of Opft W <br /> Mm&V Aft*—CKy &TATE ZIP <br /> MCCOM <br /> 77P <br /> N i CotaaEttr. <br /> TMIIIID PAw"8n&m 1woa C-mnplete if BRIWV Pady is different ftmPropwty Owner'orF iicbff~above <br /> suWass NUN � e o MEentlorc�. <br /> CRY &T TE zr <br /> d0001t1I2dmt�g forfses and ohwgM OMER FACILM/BU8Mf a THftD PARTY BUM <br /> Md(3 <br /> Diu[NG AND COMltJANCC AmNowt rnct�vT i,the undersigned Appiraet,certify that I am the Ower,Opassor,or Aafborited Agent of this Business,and I acknowledge that all PAt tuT F� <br /> PFJYALnES,ENFl ftCEK NTCM4RGET and/or HOURLTCk4xGE5 associated with tis operation will be billed to me at the address identified above as the ACUOUNT for this dee. I*No earthy dug <br /> ae information,provided on dds application is tree and correct and that all regulated activities who be performed In accordance with all app8eable SAN JoAQM COUNTY Ordinance codes and/or <br /> Standards and STATE and/or FXDsaAL Laws and Regulations.As the mWersigoed owner,opera/or,or agett of the property loafed at the above bdiWyhi*address,I hereby audmriae the release of <br /> any and ag remits and enviroummtal assessment inforvatlm in SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT w Loon as it is avaitabk and at the same dome it is <br /> provided to me or my representative. n <br /> APPLICANT NAME(Ptswag PRwT) Tj A—/� /r•GC �. &m+ATtrAE — — <br /> TrrLE TAX ID i <br /> Die Aoomxftv AMiwF.oow@IM 04m~Dy '�1 �- Dab. b 2 <br /> t#fE>rltl0ttT10II `: AMDUMYPAID GATEt)IrPAYMENT Ow"I' RECOM Of <br /> hE8:s) <br /> i <br />