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San JMquin County Environmental Health I,lartment <br /> DATE -I_I(_13 MASTER FILE RECORD INFORMATION `'MFR" GREEN FORM <br /> �• SITE MITIGATION & LOP <br /> SHADED AREAS FOR ENDO O tOWNERID#YCASE#52cou, lO 5" UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOW/NG PROPERTY OWNER/NFORMlwN. CHECK1F OWNER CUraE,vTLravnLEwmt EHO <br /> PNOPERIYOWNERNAME /,. Fffi,,.) (Z�) 3/O - l` <br /> 1` First Ml Last PHONENUMIR ;Lor <br /> BE .J <br /> BUSINESS NAME F LADDRE88 <br /> a. ��J E-1IA <br /> Owner Home Address, <br /> YoS <br /> city <br /> STATE1,.4ZIP <br /> Owner Mailing Address YD <br /> we ,Ae Sf <br /> Mailing Address City 's <br /> _ /; State <br /> 1d ZIP <br /> CORPDRATION❑ Wf/ INDIVIDIML❑ PARTNERSHIP❑ FED AGENCY f❑ GTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL AsummeNT_VOLUNTARY CLEANUP_WATER QUALITY HW PIPELINE INVESTIGATION_LOP_ <br /> FACILITY 10 111 INV# ACCOUNTED PR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHDRWQCB X <br /> JoI�MM DTSC_EPA_ <br /> eft sz7 598 y <br /> FACILITY FILE COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE/NFORMAT/ON.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an E%ISTING Business LOCATION but NEW TYPE of regulated Business? YES ❑ No <br /> BUSINEssIFAciur/SITE NAME <br /> Fomar fr.,y <br /> SIYEADDRESS p/,J SUITE# BUSINESS PHONE <br /> 7d A <br /> CITY STATE ZIP <br /> 12' a Gli 95 3 <br /> BOARD OF SUPERVISOR DISTRICT LOCATIONCODE �� KEY1 HEv2 <br /> Mailing Address KC/FFERENTfrom Fac/KtyAddress Attention:orCare Of totabors/J <br /> Mailing Address City STATE ZIP <br /> SICCOOE CoMMELrr: <br /> APN# <br /> - 020-07 <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identirledabove. <br /> BUSINESS NAME 2. F. pn c/OT� Attention:orCare Of(opfATLss/# <br /> UQN SSoIq <br /> Mailing Address PHONE <br /> C5 I✓. t 5 C —3614 '70 S$ <br /> CITY STATE ZIP <br /> /,fps; Get 95Zyo <br /> ACcotifiiTA DR o for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that 1 em the Oamee,OPerntnr,or AutBoriudAgent of this Business,and 1 acknowledge that all PERMn'FEES, <br /> PENALT/Es,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this Operation will be billed to me at the address identified above as the ACCOUNTADDRSd'd'for this site. I also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COIMIY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,1 hereby authorae the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) NaNIk &VI K( SIGNATURE <br /> TITLE ro f74 TAX ID 2-7 _ 36 ?�L/s/ <br /> Approved By Data Accounting Office Processing Completed By Data <br /> SITE MITIGATIONCUNTPAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORN PUN PE <br /> FEE:§ AM _ <br /> �?r <br />