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San J•uin County Environmental Health Pepartment <br /> DATELP"=::4= <br /> MASTER FILE RECORD INFORMATION MFRIsGREENFORM <br /> SITE MITIGATION& LOP <br /> SHA AFAR FO EHOUSEO CASE#S�GL9J�Z UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOW/NG PROPERTY OWNER/NFORMA TION.* CHEoKfr OWNER CuRstawmyovFiLE wires EHO � <br /> PRDPERIYOWNER NAME R:. F LGn) (Zaf) 36?- 7oSS <br /> First MI Last PHONENmem <br /> BUSINESSNAME EMA LADDREBR <br /> R. F Ca�l� ;sola ;sc/n uw � <br /> Owner Home Address <br /> YoS Wes/' Pe%Ie 1 i <br /> city , ^ <br /> W�I STATEGA >,P 9S1�to <br /> Owner Mailing Address <br /> Yo we PAP- S></raf <br /> Mailing Address City / I, Stag Zip /u0 <br /> I J <br /> CORPORATION❑ INDIVIDUAL El PARTNERSHIP F-1 Fae AGENCY❑ OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVCSTIGATIoN_LOP— <br /> I: <br /> OP <br /> FACILITYID# INV# ACCOUNTID PR#IRO# ASSIGNED EMPL=L�DD RWQCB X DTSC_EPA <br /> 1F"71)D 33183 PDo52.7 598 JordNMy <br /> FACILITYFILE COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION.* <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No 19 <br /> IS this an EXISTING Business LOCATION buts NEW TYPE Of regulated Business? YES ❑ NO ] <br /> BUSINEsVFACIuttISRE NAME <br /> Fo/m t%/' t �4/M F. G4 <br /> SITEADDRES3 Surra# BUSINESSPHONE <br /> 3'8 ,P rzi <br /> CITY STATE ZIP <br /> R1,00 95 <br /> BOAROOFSUPERNSOR DISTRICT L. LOCATION CODE C�� KEY'I KEY2 <br /> Mailing Address ifDIFFERENTthose FaeDflyAoNress J Attention:orCare Of(optionall) <br /> Mailing Address City STATE ZIP <br /> SICCODE APN# COMMENT: <br /> aG - oto-o7 <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner OrFacility Operator identified above. <br /> BUSINESSNAME F G �f- <br /> Vr -r�$O/(� Adenlion:create Of(ophasa9 <br /> Rn /O p <br /> Mailing Address PHONE <br /> O 4/. ;Drie 5 t <br /> CITY STATE ZIP <br /> � 752410 <br /> AcnxwrAD&M for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: f,the undersigned Applicant,certify that I am the Once,Operator,ar Aothorized Agent of this Business,and I acknowledge that all PEILUITP££S, <br /> P£NAUIT£S,ENFORC£scEATCHARGES and/or HOURI.YCHMGES associated with this operation will be billed to me at the address identified above as the AeYOpNrADDRESS for this site. I also certify that <br /> all information provided on this application is true and correct and that all regulated activities will be performed in accordance with all applicable SAN JOAQUM COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations.As the undersigned owner,operator,or agent of the property located at the above facilitylsite address,1 hereby authori¢e the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. / <br /> APPLICANT NAME(PLEASE PRINT) AlaNIk VI S✓l/ SIGNATURE <br /> TITLE J/ r0 / f TAXI Z-7 - 36 ?}/s/ � -a <br /> Approved By Data LO Accaunting�ce Proomain#Comphstedey Data (f <br /> SITEMITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORN PIAN PE <br /> FEE:$ 2 9! <br />