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IVED <br /> San JL�uln Coyunt Environmental HealthJEC <br /> rtment <br /> DATE MASTER FILE RECORD INFORMATION"MFR" :.a 2 5 2?rEEN FORM <br /> SITE MITIGATION&LOP <br /> ENVIRON ENTAL IV <br /> SHAOEOAREASFOREHDUSEONLY OWNER IDM � CASEM PERMI /SERVICES <br /> CHEOK/F OWNER CuRRENttM YoArme 7 EHD <br /> OWNERFILE:COMPLETETHEFOLLLOWINGPROPERTYOWNECRINFORMAnON: <br /> PROPERTY OWNER NAME 1)Av l D =sOL-A, <br /> First MI Last PHONE NUMBER <br /> 1 E-MAIL ADDRESS <br /> � <br /> BUSINESS NAME �I ,�,In Fa�"iM Se�`��C� VVIVI.••(GG.11l...+ <br /> Ck <br /> Owner Home Address <br /> 4OS V<les� �i (1e S'e&- <br /> -- - STATE zip <br /> city �OC\-t ca 95240 <br /> Owner Mailing Addressv� <br /> State Zip <br /> Mailing Address City <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ <br /> FED AGENCY❑ OTHER❑ <br /> IPI / <br /> $ITE MITIGATIONENVIRONMENTAL ASSESSMENT—VOLUNTARY CLEANUP_WATER QUALITY 9,IOW PIPELINE INVE3"fIGAT10N_LOP <br /> -2£ �.,} rgFry art. tiY <br /> FACILITY ID# IN VM AocouNr ID <br /> z <br /> 37-77` <br /> FACILITY FILE COMPLETE THE FOLLOWING BUSINESS/FACILITY/SITE INFORMAT/ON <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LocA-nON but a NEW TYPE Of regulated Business? YES ❑ No <br /> BUSINESS/FACILITYISRE NAME ��� (� F"a,lM 52 r�t GG,S 0,& F F Land <br /> SUITE M BUSINESS PHONE <br /> SITE ADDRESS <br /> �'ron e 12oacl 20 -7 --7055 <br /> $CA Lp <br /> CITY Olil 9S36G <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE <br /> KEYi KEY2 <br /> Attention:or Care Of(optional) <br /> Mailing Address ifD1FFERENTfrom Facility Address <br /> STATE Zip <br /> Mailing Address City <br /> SIC CODE APNM -26 O(e `1nC� COMMENT: <br /> 4! ave o <br /> THIRD PARTY SICCING INFO: Comp/etc if Billing Party is different from Property Owner or Facility Operator identified above. <br /> Attention:orCare Of (optional) <br /> BUSINESS NAME <br /> PHONE <br /> Mailing Address <br /> STATE Zip <br /> CITY <br /> for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned App c— that I am the Owner,Operator,or Authorized Agent of this Business,and I adcn'twNled'eethat aloe�ERMt IFEES, <br /> a�e i <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address Identified above as the y <br /> information provided on this application is true and correct;and that all regulated activities will be performed In accordance with all applicable S DAQUIN OUNTY nan odes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above f9,9ty/site add ss,I a the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ae a t the same time it is <br /> s soon as s av <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) (i,- LG SIGNATURE <br /> TAx ID# <br /> TITLE —Pre / <br /> 1 Date Accounting Office Processing Completed By e Dats / <br /> Approved By ,.. <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT M CHECK M RECEIVED BY <br /> FEE:$ �� <br />