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San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION "MFR'' GREENFORM <br /> SITE MITIGATION&LOP <br /> SHADEOAREAe FOREHOUSEONLY OYMER IDS CASE I{ UNIT IV <br /> OWNER FILE:COMPLETETHEFOLLOW/NGPROPERTY OWNER AlFORMAT/ON: CxeclixOWNER CORRExrtrommEmrxEHD� <br /> PROPERTY OWNER NAME ( ) <br /> First MI Last PHONE NUMBER <br /> BUSINESS NAME EMAIL ADDRESS <br /> Owner Home Address <br /> City STATE ZIP <br /> Owner Mailing Address <br /> Mailing Address City State zip <br /> CORPORATION El INDIVIDUAL El PARTNERSHIP El FEDAGENGY❑ OTHER E) <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILRYID# INV# ACPAUNT ID PR#I ROM yip E IYA i 4QTy3C1� E ' <br /> 2L, I <br /> FACILITYFILE CoMPLETETHEFmcw1NGBUSINESS IFACILITY/SITE/NFORMArlow <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINEssIFAcu-nY1SIre NAME <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> Cm' STATE ZIP <br /> BOARD OF SUPERVNORDISTRICT LOCATION CODE KEPT KEY2 <br /> Mailing Address lVDIFFEREPYTfrom Facility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE 71P <br /> SIC CODE =1 <br /> APN9 �.Commahr: <br /> THIRD PARTY Bruno INFO: Complete if Billing Party is different from Property Owner or Facility Operator idendffedabove. <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE LP <br /> AFfR1aIIA0OSE8Y for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOYn.EOGMeNT: T,the undersigned Appliesni,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all P%IvUiT FRFs, <br /> PRNALT,S,ENFDRCRMENTCRARGEs and/or ROURLYCHARGEsessociated with this operation will be billed to me at the address Identified above as U¢AtxoUNTADDRess for fish.H. 1 dao ardfy that all <br /> information prodded on this application Is true and wrrecl;and that all regulated activities will he performed in accordance with all applteable SAN JOAQUIN COUNTY Ordiu mee Codes and/or <br /> standards and STATe and/or Faosam.Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above fadgty/site address,1 hereby authorize the release of <br /> any and all results and environmental assessment information M 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) SIGNATURE <br /> TAX ID# <br /> TITLE <br /> Approved By Dale Accounting Office Proeeaaisg Cumplatatl By Data <br /> SITE MITIGATION AMOUNT PAID GATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECR# RECEIVED BY WQ�fj Pk {tPI <br /> FEE:$ G., <br />