Laserfiche WebLink
San J uln County Environmental Health f lartment <br /> 4 DATE 6 I 1 �. / 11 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> _ SITE MITIGATION & LOP <br /> SHADEGAREAS r0A EHD USE ONLY DWNERIDR OAeER UNIT <br /> IV <br /> Ipp OWNER FILE : COMPLETETHEFOLLOW/NGPROPERTY OWNER fNFOR,�rTfwyo v Cxecx/F OWNER 0we: rcrotvFzLEwmEHOEl <br /> III PROMMOwNERNAME � /Q�C r �'OP� / rrA+/O %Re� Y / <br /> IN Flat MI Last PHomblumam <br /> BUIDNESSNAME EMNLACORESS <br /> I�p/P/wF ANE / N VCs:7 M E/�TS <br /> Owner Hama Address <br /> 5 3 /3 ,L�A�p x Dz + dc <br /> CRY STATE <br /> STATE ZIP <br /> 4. CA 9Sa� 5 <br /> Owner Mailing Address <br /> Melling Address CKy State Zip <br /> CORPORATION ❑ ' INOMQUAL❑ PARTNERSHIP ❑ FEDAGENCY ❑ OTHME] <br /> SITE MITIGATION _ ENVIRONMENTAL ASSESSMENT_Vo W MARY CLEANUP —WATER QUALITY_ HW PIPELINa INVISTniIATION _LOP Je� <br /> FACItaTYID # INVR AccouNTlD2 6PR#/ ROR Ae oNED EgpLovEE . LEAD AOE/)cY. EHD_RWQCB_ DTSC _Elo <br /> FACILITYFILE COMPLETETHEFOLLOHWGBUSINESS I FACILITY / SITE JNFORMAT/o/v <br /> Is this a NEWBusiness LOCATION notpravlously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YEs ❑ No EFW0 <br /> Is this an E2lsTwo Business LOCATION but a NEWTYPE of <br /> regulated <br /> ateed Business? <br /> YEE [I No 0' <br /> BusmEBB/FAniurWSRENAME T ! ' Urb spLIrS E: ) pVI <br /> SatiftlaEsa SURER BUSINESSPHONE <br /> � oBS C-AST t=.�EMJa7 s7",cG-C- . <br /> cm S' ToCV- rol.1 <br /> STATE LP <br /> BOARDOFSUPERVmnR OIeTRIOT LocAnONCore KEM - - KEY2 <br /> Melling Add rea ; ffDIFFERENrhwn FaWIlfyAddrsas Altentlon: wCare Of (Opilawal) <br /> Melling Address City STATE 2116 <br /> 810000E APN# COMMENT: <br /> THIRDPARTYBILLINDIN11107 CoMplete If Billing Party Is different from Property Owner or Facility Operator identified above. <br /> BuaumNAME - Attention: a Care Of (opCala/J <br /> /)'IC A'SSOC ( A7'6 / NL <br /> Mailing Address Pxoxe <br /> / l / 7 Loa✓E ei}Lo44 AVEAiyG su ( TC- .Zint / s792zz / <br /> Om STATE Zip <br /> Ftifc L&.r i0 Cil 9s,3 Sl <br /> AG(M1/E2AQOBEBS for fees and oharges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND Co%upLfANm ACKNOiKEDGMENT: I, the undersigned Applicant, certify that I am the Owner, epermst, ordatltarltedAgeat of this business; and I acknowledge that all PMu�FEEsr <br /> PcxUxEY, ENF0x&vENFCjmGEYand/ar Hor rCisimssmuodafed with this operation will bebilled tome at the address identified above " theifixmmTADDR for this site. 1 also cera(, that <br /> all information provided on this application is true and correct; and that all regulated actiillm will be performed in accordance with all applicable Stu JOAQIILN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDEML Laws and Regulations. Asihe alder igned-e+merropersferrorngetN-of�lirpropergNeeetedaN4cw alffyhifeaddres�Hrerekywul:.�.:;E��.rrka.,�,: <br /> en,y sit 5 h is a on'Fable-end-eHhrsameiime iFet <br /> ProridedieRlsaPmyaapinwntaliaa <br /> APPLICANT NAME (PLEASE PRINT) Ec�C� lQc'SSa c,� �S Lu+ c _ . SIONATUR , +,�� Z, d t>AT-km <br /> TITLE TAX ID # e13111, v.� o^lY <br /> �vzti vw ✓ LIG - 6319LOW <br /> Apptovetl By Date Accounting Ones Processing Completed Sy I Date <br /> SITEMITIGATION AMGUNTPAID DATE DF PAYMENT PAYMENTTYPE RECEIPT # - CHECK # RECEIVED BY WORN LANPE <br /> FEES <br />