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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE ( MASTER FILE RECORD INFORMATION MFR» GREEN FORM <br /> I 20[� __ _ _ _ _ SITE MITIGATION&LOP <br /> y,"vEa w'INI FOR EHD ONLY OWNER IDR CABEi « UNIT IV <br /> ATCNECRMOWNER Ii CURRENTLYONFILEW/TN <br /> OWNER FILE:COMPLETE PROPERTY OW NERI RESPONSIBLE PARTY INFORMION: END <br /> pAppgWYOM161NALMF � / <br /> FRET MI LAST PHONE NUMBER <br /> 50VAAL 011,BI�MNYIME �ADDRESS <br /> OEWDt HOME ADDRESS l O 30)4 IU 120 � <br /> V <br /> CITY, ' 1A I v 7056 STATE ZIP Is t r <br /> OI MMMIGAWRFSB Q QEtK Gvzo6s <br /> YAEYOAm1FlMCm SArt,t TOS <br /> ❑CgiPO1U1TgN ❑INDIVIDUAL El PARTNERSHIP ❑GOVERNMENT ADENCY ❑RESPONBIBLE PARTY ❑OTHER <br /> $TE MITIGATION ENVIRONMENTAL ASSESSMENT—VOLUNTARY CLEANUP---WATER QUALITY— HW PIPELINE INVESTIGATION— _LOP <br /> FACMLTY1108 INYR Accouter ID PR If RIO ABBI SO EwLoYEE LEAD AGENCY:EHD_–RWOCB_DTSC_EPA_ <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRfiomNEFTAL HEALTH OEPARTMENT? YES ❑ NO0 <br /> IS THEISM OOSTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES No ❑ <br /> BIMMIEWFACRITYISRFJP RWECT NAME <br /> 81EADDIoif PROdEQTLOCATION BYTE# BU I"Gas PHONE <br /> T ST. a1(, Sit-sg3zz <br /> CITY S�.y��.ro` I STgTE LP T Z'^� <br /> BMMOFI(/SUFER(/ vlSoa DlvlaragT LOcATIox CODE KEY1 KKEY2 V' Lv <br /> W IUPKI ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION.ORCARE OF(OPT1QiUIJ <br /> logfo TMDE ?. v - 0 C ISTINA Y41 mi-iI i&ffT <br /> YAf)MGAODREBS CITY �YT�TE LP <br /> L4 1-10 Co'lx �A (Ti <br /> sic CODE APNA Cw art: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY ISpDIFFERENT FROM PROPEROW�NEER OR RESPONSN3LE PARTY IDENTIFIED ABOVE. <br /> EGLUILoN BUSINESS C-t�ERpg15Es �{YY SKILL (-'1L [CiMpAN'ITIENTOWORCAREOF(OPTMNAL) <br /> ML ADDIBM PHONE <br /> /�. Q9 5 .. S, WILMINGTON D�'. KZS) 41p3�- 116 <br /> cm ST,TTE�♦7 LOIS <br /> AGcouNi ADDRE88TO SENO FEESANDOHARGES: OWNER❑ FACLRYIBUSINESS❑ THIRD PARTY BILLING❑ <br /> BHL%G ARO CWIP II E ACKNfIN'LEDCMENT: [,the undct igaed Appllennf,sertif)'that I fRfDe/Ameq GperRd,Aarh m--d 4gene,or RerpaluiNe Party and I.&nmoIM,that all PFsno,FFFS. <br /> P£t.Y.TTEI:E\FplmorsTC/F1RG£S and/ar floE'RLY CHARGES asesei ted NIIh this pr0)ert ailf 1M Milled to on,Y the address identified tlbme as the A(CO[\T'DoaESS far this site. 1 ah.rertily tint ill <br /> iffvnadow provides]on this application is[me and correct;and that NI regulated aclambes ui be performed m necordame oith all appRcable SAS JOAQEIN COLNTY URUINANCE CODES a WM <br /> STAN.alms avd SrATT md/nr FEDEwu Lans and REGULATIONS. As tbu a sdersign ri fi—..Ofvrevr,.ltvA.xi:rd,lrenr.nr Re.PnnsiMe Pvrry fonts Prnjxt larnted abv.'e ander L eilhy;dte addresa.l <br /> henbv nothmbe the rehme of any and all results,reports,and abet-emironmenml asees.nrwt imoraviov to S .IO.AOHTN CDUSIT ENI IR NIENTAL FIEALTH DErdRTIILYT as sann as it is w,d , <br /> mel m The same Time it is pro%ided to me or In,representative. <br /> APgECANr NAME(PLEASE PRINT) SIQNATURE <br /> TITLE TMIDR <br /> AF/AO/®Be DATE ACCOtM1Nn OFFICE PRBCE®HaCgBIErEp eY DATE _ <br /> $ITE 111TIGATpN AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE R£CGPT9 CHECRR RECENED BV WORN PtAM PE <br /> FEE i <br />