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San Jd',,�in County Environmental Health Dc%';tment <br /> es �! GREEN FORM <br /> ' DATE - MASTER FILE RECORD INFORMATION MFR SITE MITIGATION&LOP <br /> `' UNIT IV <br /> 9HAQp_AREAti_FQREH0U9E0NLY r :,OW et'.10 < �J' <br /> CAEiiNj Jim = <br /> OWNER FILE:COMPLETE ESPONSIBLE PARTY INFORMATION.' CHEmew OWNER CUMEmr1.rcmFxEwtrH EHO <br /> PROPERTY OWNER NAME / <br /> FlrSf - M7 Last <br /> PHONENUMBER <br /> I E IMIL AaDREBS ' O W <br /> BU$INESa NAM! ✓W�r fin Ow- K Ya re c <br /> Owner Home Address �'W [7r N+t ✓`� <br /> City STATE ZIP <br /> Owner Mailing Address <br /> [Wflrig Address City l f Vtn'61"r 4` Blake /1 ,[ ZIP .9 2''4 0 <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP D QOVERNMENT AGENCYRESPONSIBLE PARTY ©OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT J VOLUNTARY CLEANUP_WATER QUALITY HW PIPELINE INVESTIGATION_LOP <br /> I s < t <br /> FACILITY FILE: COMFtM BUSINESS/SITEI PROJECT INFORMATION.' <br /> Is this a NEW Project LOCATION not previously regulated by the ENWRONIAENTAL HeALTH DEPARTMENT? YES ❑ No <br /> Is this an ExISTING Project LOCATION but a NEW SCOPE OF WORK? YES li+ NO ❑ <br /> 5U8IHE881FAgLiY1SITEIPR0J£CTHAME V <br /> q (G,M !n Lt <br /> SITE ADDRESS lPROJECTLOCATION n J f !'..�e,,r IA..e 5 SUITE N BUSINESSPiiONE <br /> V�j [ I VNO v'(.� cry <br /> CITY / C' ..p STATE 70P 96-Z'10`-Z'1 0 <br /> Ma�iioa�tllrrcllVaauDlrrllior �� }:CooAlloriloaMk' " Kdri "+ / ISR+ �; • <br /> Mailing Address HDlFFERENrlrom Fev1WAdWv" p Attention:orCare Of(gpdonso <br /> We—5 f <br /> Mailing Address City L r, ff STATE { ZIP, <br />� CSI�.QCOR-.y ' ,. � '�� �.�' a �_ :� k �; �'�fi.- d..b �f • >- t s, -Y ��i" %�. .�.�,. <br /> } 4 -a - .� (F , •' _ .Tit: <br /> THIRD PARTY BILLING INFO: Complete if Oil IIng Party is differenIt-from Prope rty Owns orRels onalbIa Party identified above. <br /> SUBINESSNAME Attention;or Care Or(opoonag <br /> Mailing Address PHONE <br /> 1 CITY STATE ZIP <br /> I <br /> y AgwyAIAami its for fees and charges OWNER FACILITYIBUSINE5S THIRD PARTY BILLING <br />+ Ilu.t.t�r. tet=i:O\tettstit a Ac c.�ocr{.Fatrsfl_t r: 1,the undersigned Applicant,certify that I ani the fhvrrer,Operafor,A+nLpri ed;Egerrl.or Re)ponslblr Parer and I nckiiowif(ige that att Pr'a.+rrrF'eFs, <br />{ l'F,SAr.irls,I:,�Fr+m-svrsrf'rr.trrr:Fs andfar 11olm.r l.'rraerts nssecialed nigh this project will lie billed to me at the address idenlifird abose as Ihe:cf r+nr•t rr acs for this site. I(kilo ecrltfy flintall <br /> i information provided on this application is leve and correct;and that all regulated activities will be perforated in accorrina(e with all apipiicabic Ss?t:{tt:SQlati'C.'nt.�tl'Ordinance cades and/or <br /> 5tandard5 anti STAID andlar FFDFR,tl.I.nna and Itegul:ttlnns, An the onttersigncd Ois iter,Operiilor,Atilhorired Agent,or Responsible rarly for the project located chose under facilitylsite nddresy 1 <br /> hereby nalhorire the relvalic of any and allre.9alls,reports,and olher emirarifnenhll a%sessalcnt information to SAY:OAQ1!IN COUNT' I': ')�1IF:�I r\1.IFF., "fit FlF:P:\R 1"an:\1'tis loan nq it <br /> is available and at the same lime it is provided In Inc or my rcpresminlivc. <br /> APPLICANT NAME(PLEASE PRINT) d1(t SIGNATURE <br /> r� f TAX ID# <br /> TITLE p)o\ri1 <br /> Ap vad 8 Dal. Accounting offt"l Procsaalnp comptstsd By <br /> $tT!MRttiATIDN AMOUNT PAtD OATS OF PAYMENT PAVIIENT TYPERlCEIPT N R CNEOK•/ REOEtNo BY "Wollll 01.'AN. , <br /> r <br />