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0 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE MASTER FILE RECORD INFORMATION LLMFR" GREEN FORM <br /> J SITE MITIGATION&LOP <br /> SHARER AREAS FOR EHO Use ONLY OWNERID# DWOD)793[7 CASE III UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHEcKiFOwmER/SCURRERrzroomFnEw/re EHD� <br /> PROPEITIY OWNER NAME ( ro lOQ;5 (To g. c va l a yl (to?) 8 3 3—'5 38 111 <br /> JfFIRST Ml GST PHONE NUMBER <br /> BUSINEs3NAME ��-•.^ Ltd LE-MAILADDRESS <br /> OWNER HOME ADDRESS 7 <br /> VL <br /> l-7r�ZS <br /> Cm I STATE <br /> l.r iT LP <br /> II C ( S 7 17 <br /> OWNER MAILING ADDRESS -6rhy/+—.u' / A ve <br /> MAILING ADDRESS Cm Ws /L^V STATE ZIP <br /> ,p CORPORATION ❑INDIVIDUAL El PARTNERSHIP D GOVERNMENT AGENCY D RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FAOIDTYID# INV# ACCOUNT ID PR RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB_DTSC_EPA_ <br /> -111? e D .1vHNuq <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS ANEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES N No D <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No <br /> BUSINESSIFACIUTY/SrMJPROJECT NAME Fe�x C7roun r, C <br /> Qt�LI o'�e <br /> SITE ADDRESS I PROJECT LOCATIONSUITE# BUSINESS PHONE <br /> b! GJ, '414y V. ggSSo 1 N <br /> CITY CFS ^ CA ZIP 95377 <br /> BOARD OF SUPERVISOR DISTRICT LOCATIONCODE ( KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACI Lm ADDRESS > ATTENTION:ORCARE OF/OPT/OWALJ <br /> ;LC/3 0 Iea4"-0h 544A t22 Ft, <br /> MAILING ADDRESS CITY STATE� ZIP <br /> SIC CODE APN# COMMENT[ <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME �Ur .Qjlrl S � Y\ Y��r//� (/\/If TTENTION' A'EpF OPT/ L� � <br /> L� I//Y'/'f !Li /k <br /> MAILING ADDRESS �/ <br /> z o metivai SIt�rT� !vim- PHONE l(`lg-GSt <br /> CITYS&-`L dq/ NAen^ STATE Ifn ZIP <br /> A'CCOUNTAODRESS TO SEND FEES AND CHARGES: OWNERD FACILITY/BUSINESSO L•THHIIRD PARTY/BILLING, <br /> BILUNC AND Compi.IANCE AcicvowLeocMENT: 1,the undersigned Applkanl,certify that l nin the Ouaer,Operator,AwhorizeJAgenr,or Responsible Parry and l acknowledge that all PERUIT PEER, <br /> PLNALriG,FNFORC&1LUTCimRGt and/orHousILYCnIAGer associated with this project NII[he billed la oIDaI lbon1dros identifiedabaVC as IIICACCOUNTAiwam for Ihls Slle. I also ttTllfythudall <br /> iMoramt of provided on this application is Irmo and coned;and Ilml all r,,,kded activities will be performed in accordance adds all applicable SAY JOAQUIN COUNTY ORDNANCE COnES and/or <br /> SI&NDARos and STATE and/or FEDERAL Laos mill REGULATIOPS. As the lon crslgnsd OmYa,,Diatom,,AutherizedAgent,or Responsible Parry for Om project located above under fadtity/sile add..,l <br /> hereby outhnrizc IIIe release of any and all results,reports,and other environmental assessment information to SAAJOAQUI.N COUNTY E.WIROXMENTAL HEALTII DEPARTME.NT as soon as it Is available <br /> and a1 the same time It is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) � Mr (_tg,(t,/1?.,/8 ViUg SIGNATURE <br /> aT— <br /> TITLE SCltitO✓' P✓ eG21r• rAzlD# I L V <br /> 'y <br /> APPROVED BY DATE gCCOUNDH I OFFICE PROCESSING COMPLETED BY DATE p <br /> SITE MITIGATION AMOUNT PAID DATE)FPAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED SV WORN PLAN PE <br /> FfE:S'�7y 3�S PHt�L+K �xJ(tl QoLtav a.Q�U <br />