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s� <br /> �r <br /> San Joaquin County Environmental Health Department <br /> DATE �{ /L MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> l ---------._..... _ - ----_- —_ SITE MITIGATION& LOP <br /> SHADEn AREtiS FOR ENDulie QNLV OwNERID# CASE# UNIT IV <br /> OWNER PILE:Ct7MPLETETHEFVLLoWING PROPERTYOOWNER lwomw'ioN.' CmroxiF OWNER CLwNENrtrcwFxe wirm EHO <br /> RT <br /> PROPEY OWNER NAM£ I I/U _ Cts `� +v 1 (7`L)__-3 — 36' <br /> C_ I k oW I r1C.G. <br /> FNS M1 Last PHONE NUMBER <br /> BUSINEss NAMEE-M <br /> AIL ADORess <br /> NCS �U4f.,mJ io+) - <br /> Owner Karns Address <br /> CRY STATE =71 <br /> Owner Mailing Address <br /> Mailing Address City rr l 1(/ gft ZIP L� <br /> WCt:G IP <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AOENCY❑ OTHER <br /> SIT!MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATot QUALITY_HW PIPELINE IlwasmeATION_LO /// <br /> FACILITYIDXINWf AccouNTID PR ROa AgsMiNepEMPLoveE LMAoaNcy,EHD—�ZRWQCB_OTSC_EPA <br /> _ <br /> �i �n�J p( — <br /> FACILITY FILE COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITEINFORMATlow <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an ExISTING Business LOCATION buta NEW TYPE of regulated Business? Yes ❑ '-^NO <br /> BUSINESWFACnJTr/SITE NAME <br /> SrrEADDltetse V I 3utTe# BuslrvEssPkoNe <br /> lel Nal � ►w u 18 Oofo Rod <br /> Cm ` SJATE ZIP C 5700 <br /> BOARD OF SUUPKE <br /> Y2 <br /> LOCATION CODE f K"I K2 <br /> 1 Mailing Address N,DlFFER from fAlcAtyAddrvss Attention:or ears Of(optional) <br /> Yi 0 Jt Wo <br /> Mailing Address City 5 nrE ZIP <br /> SIC CODE APN iI COMMENT: <br /> THIRD PARTY WILLING INFO: Complete if Billing Party is different from Property Owner orFacility Operator identirled above. <br /> BUSINEBs NAME .I {T�'',,t Attention:orCare Of(optional) <br /> Mailing Address PHONE <br /> CITY / ATE ZIP <br /> AGG`.Of�tZ�/(I AOOBES9 for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COtIPLIANcz AckNox%ixtIGMF.NT: 1,the underli=ned Appiicant,certif_l.that I Am the Uwrver,Operoror,or Aurl—iied Agexr of this Rusiness,and I ickm,wledge that all PFRAIITFF.LS, <br /> Pf:'NaLTIES,FNroAc&ue.ArCH"Rcta andior Hurxer CNAxcts associated with this operation will be billed to Ise at the address identi0ed above as the ACCOUNTAOlNfF-SS for this site. I also certifv that <br /> all information provided on this application is true and cur rect',and that all regulated activities will be herfornied in aecordmtce Wath all aPPlicable SAN JOAQUIN COUNTY Ordinance Codes andiar <br /> Standards and S"CATF.and/or Ftoen,%L Laws and Regulations.As tite undersigned owner,olwator,or agtat of the property located at the above faeility!site address.1 hereby authorize The release of <br /> any and all results and tavirunmental assessment information to SAN JOAQU4N COh YTY FNYIRONMF.N'I'AI,HEALTH DF.PAR'rlLl' T as sog1l "A11,111C and at the same time it is <br /> prodded to me or Inv reptrwntuk c. l <br /> APPLICANT NAME(PLEASE PRINT) �(�l� ��%f( StGNATURE <br /> TITLE /d f' Wr'� S l��c �✓l ut.�✓� /1 cF�lt Q TAX ID# �yf Z06 <br /> Approved By Data __ Av...rfing Offi.e Procesai Cum la6ad B Date <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE REOEIPI'# CHECK# RCCNVED BV WDRK PLANPE FEE:$ jW �j t I gz� <br />