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f San Ji uin County Environmental Health Miiana rtment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> UNIT IV <br /> SH{w"DflgA. F4AEHDUeE9NLY OAsatti.3 .: pi <br /> OWNER FILE:COMPLETE ESPONSIBLE PARTY INFORMATION.' CNEClfrF OWNER CURRENrLYdNF1LEti?TH EHD <br /> PROPERTY OWNER NAME 0%) 503-3151 <br /> First Ml Lest PHONE NUMBER <br /> BualNEse NAME d 42 �� ow,ADOREea Va It vT.CD w--] <br /> �r <br /> Owner Home Address <br /> citySTATE ZIP <br /> Owner Mailing Address /�r t■ 0,q f AIM <br /> l <br /> Mailing Address City tr f '7 t/n Av 7 J �1� 1+[ Stale ^ f Zip 93 <br /> n �O <br /> ❑CORPORATION t I«M,[:1 INrD`I^VIDUAL ❑PARTNERSHIP Q GOVERNMENT AOENOY RESPONSIBLE PARTY ©OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT�VOLUNTARY CLEANUP_WATER QUALITY_MW PIPELINE INVESTIGATION_LOP— <br /> 1'FJIAIt]ttillD ,, IiIMf R 1)oOMll?ilp*` PR1/1RO.t'F A• ^lli11111. Y� r14 <br /> U Eff 1 E- 1 <br /> t { <br /> FACILITY FILE: COMPLETE BUSINESS Ir SITEI PROJECT INFORmArION. <br /> Is this a NEw Project LoCATIoN not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes 0 Na ' <br /> Is this an EXISTING Project LOCATION but a NEW SCOPE OF WORK? Yes No C) _ <br /> SUSINESBIFACMITYISITEIPRo ecT NAME ,/a, A.M t <br /> SITE AODREss I PRo ecrr LOcmm 1 Z a �t I _-,_ t� .-e t! h SUITE M SUSINESS PHONE <br /> STATE �ZIP <br /> 957,10 57,+O <br /> CITY {. <br /> r I�DAllg.01!St1FlJlYlagll DlarRiOT i '4 iI��N11d.000E r rEt�EY t 1 # x •, "° 1 ! F Y <br /> j) <br /> Malting Address NOIFFERENT from FicNltyll aWrives Attention:orCare OF(a pffmaq <br /> f. R STATE� ,{ 71P <br /> Mailing Addt*as City Ill�(y/1L/W !Nr J� <br /> k T"iito PARTY FILLING INFO:_ Complete if Billing Party is different fromPro"rty Owner or Responsible Party identified above. <br /> I BUSINEeSNAME Attention:arCare Of ilopgonali <br /> I Mailing Address PHONE <br /> e <br /> CITY - STATE ZIP <br /> AQWMATAi9M=for fees and charges OWNER FACIE_ITYiBUSINESS; THIRD PARTY BILLING <br /> f3u.t.tNc nrrtr CnstPLlascF'.AcsN'Owt.t•:nintt:NT; 1,the undersigned.Applicant,ceriif)drat I am;lhe fTlrner,Operalnr,:%iruborlxd;tRerr6 or Responsible Par&and 1 arkno"Iedge that all 1'L'x.+RfFF'Fc. <br /> PF.¢U.rfr.:v,li,cFnrrri urvrf'mtnr:r;.c andlar IlntxcrC}rcRGF-;:associated pith this project will lie billed to me at the address idcnliried alime as thefor this site. 1 also certify Ehnt all <br /> information provtdel on this application is true and correct;and that gill regulated activities rill be perrormrd in arcardagire pith all applicable S%N JOAQUIN COU IV Ordinance Cmles and/or <br /> Standards and STAT t•:nadfor FEeeRAI.Lutss find Regulaliuns. As the undersigned Onne•,Openilor,Aulhorired Agen6 ar Rnponsihle Party for the Itrojcct located abase under facilityAltc add&,%%,l <br /> hereby aulhorire the release ornny and all results,reports,and other cnsirandnentnl gissessmcnl Inrmrmation to 5Ay JOAQ11N CON:NT1' I fF:, TH l)ta'AR rNTENT as%min sit it <br /> is available and at the%nine lime it is provided Io me or my represeninth'e. <br />� APPLICANT NAME(PLEASE PRINT) V py j cLJ !&e <br /> (J� <br /> SIGNATURE _ �• <br /> d TAX ID N <br /> TITLE I fif/iGt�nL r✓vNt l r V 1�f�t' beef Aa a 9'f —1 I Z(04 51 - <br /> Ap ed at Accounting Office Procasa3ny Completed Illy Dale — <br />` &W MITIGATION AMOUNT PittO OATd OF PAYMENT PAYMENT TVpE iZEQa1Pr 0 ¢ CNEDN/ R1101101110 OV 'Wlfllk P,LAN,PE!`. <br /> i ` <br />