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i <br /> San Joaquin County Environmental Health Department <br /> t - I <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE I <br /> ■■MITIIGATONy■ &LOP <br /> SH n9Eq AgEAS FQS E'Ipli...��QHi r' OWNER'IG1K <br /> CASE# UNIT ■V <br /> S 16C) 6S3 <br /> OWNER FILE Wommcm7wr--oLLowNGPROPERTYOWNERINFORmAnom CHECNlFOWNER C(/RHEMLYONF116n7THEH© <br /> PROPERTY OWNER NAME y - �,.. . <br /> First 11J1 Last PHONE NUMBER <br /> BUSINESS NAME E-hwl.APDaess <br /> Gc Y <br /> Owner Home Address <br /> City STATE LP <br /> �1� 9S2f <br /> Owner Mailing Address elr�� <br /> f _ .,..� <br /> Mailing Address City state <br /> CN 7jP qsz I <br /> CORPORATION'© INDIVIDUAL,© PARTNERSHIP❑ FED Af3 av© OTHER <br /> SITE MRIOATION w ENYIRO81MfNTAL A9BE88€NENT VOLUNTARY CLEANUP_YI/ATEi't QUAUTY—HW PIPELINE INVE"GATIOlt—LOP_ <br /> FACttrrrlD# INvN AOCo*ID 046WROW i aFr <br /> bWS9 13 <br /> FACILITY FILE COMPLETE TNEFoLLow/NG BUSINESS I FACILITY/SITE INFoRwiwN: <br /> Is IVIS a NEW Business LaCATION not preVlously regulated.by the ENVIRONMENTAL HEALTH DEPARTMENT? Yrs D NO <br /> Is Ws an EIBSTiNG Business LocATioN but a NEW TYPE of re'btilated.Buslness? YES 0 Not <br /> PUSINEWFAC1L17YISITE NAME <br /> SITE ADDRESS surra# BUSINESS PHONE <br /> Cm - - ,. STATE ZJP r <br /> BOARD OF$LAE.RYIEOi4 DI9TIdCT LOCATION CODE KEYS KEv2 <br /> Mailing Addresa If DIFFEREW from FaclUtyAddress Attenuon;arcare Of(ap60007 <br /> Mailing Address City STATE ZIP <br /> SIC f:dOE APN# COMMENT. <br /> TNinn PARTY BiLL.ING INFO: Complete it Billing Phrty.:is different from Prop"Owner or Facility Operator identiTed above. <br /> BUSINESS NAME Attention:orcare Of fopubnalf <br /> Mailing Address PHONE <br /> 'T 2�9) ,t I ebb <br /> Crfy ST zPp,�rl <br /> .. .... .� -t�?L <br /> A=WAM-E&RSM far.fees and charges 616iR FACILITYIBIISINESS TH D DPRTY BILLING <br /> BILLING AND Ct HIJANCE 4CIS-IQOWLEDGM$NT: [,the undersigned Appilcany'cerdfy that I am the Owner,Operator,or Authorized Agent of this Bmfness,and I acknowledge that all PexxnT Pejs, <br /> PE1 Auras,EIV mcEAlClY7 0uNGEs andlor 1fovRLYCYxwrE4 associated with this,operation will be billed tome at the address Identified above as the Acy�[i—yTADnxsss for this site.I also certify that all <br /> information provided on tb€a appikatlou is irate and correct acrd that ell regulated activities will be performed in aceordanee with All applicable SAN 3VAQUIN COtINfY Ordinance Codes anular <br /> Standards and STATE arid/or F EDERAI.Laws and Regulations. As the undersigned'awne,operator,or agent of the property located at the above facillty4ite all 16 1 hereby aufharize the release of <br /> art]and Al results And euviromnental.atsesarmnt information to SAN JOAQbIN COfiNTY ENVIRONMENTAL HEALTH DEP ENT as n as€t is iiab€e and at the same tirim t is <br /> provided to me or my representative. -SIGNATURE -- <br /> APPUCANT NAME{PLEASE PRINT) <br /> _. - Lam. 1`'iGIY=�U^ � <br /> TITLE f"► lden f 1 TAX I D# <br /> Approved By 00" ..AwmnNng Of ito ProtoWrt9 Cortkptated By Date g� <br /> sire MITI!n AMnUNT PAMGATE Oi PAVuEwr PAyue4r TYPE REcewT# CHECK s RiioovEo By WORi�PLA l <br /> FEE: <br /> e <br />