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San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> SKAM ARIA!FOR EHa uat CHU OWAM MS CA"* UNIT IV <br /> OWNBRPILElCompLc rrwFou.owwoPROPERTYOWNERlrmmATAON. CHrcx.FOWN ERCuavmyoNm--*r,+EH0 <br /> PAOPtRtY owNdr NAw WA LK f-K. (zat T S 7 <br /> Fa-d Ml I Last PrOhf NUMM <br /> &;unison NAM c ITY d F Jrreek7b t-1 k*-#AL AwRasa <br /> Owner Homs Address 4-4G )V • & L Dof-,?9D0 S7. XM -S /7 <br /> ow..rMa�ingAdt�... � <br /> Wing Adds.Cly zip <br /> CorwoRAT)ON❑ ❑ PMTNMMRsta❑ ro AaeCr❑ orxex <br /> SM MfTNMATIOM_RNYMON11tlsfTAL ASs6N1 MR_VOU Mff'ARY CLAAMtuP_WAr=4uALMY_HW►anon 6rv10a7wlTI M—LOP <br /> kavty 10 P b" Aootwur 10 PR N RO/ AtaloNao frnovw lsAo Aotrror!H0__R1MQC0 OTl;C`EPA, <br /> PACUTY PILE C fB rHEmu.owbwo BUSINESS I FACIUTY/SITE bit vmAraw <br /> Is Ws.New 8ulllrws,t aeAr►oN not pmvbtstY rspuisfed by the F.ItvtltfxiMMTAkt*AL I DEPARTUINT7 Yea ❑ No <br /> Is Uis an E)MMW Bushwe LocAroN but a NEW T 11 of regullatrd&sirwa? YES Kr' No ❑ <br /> 81�1113"EWTACLMYOtre NAM GIT Y O F S70 GK TO,uV,6 GA N <br /> Stn Aooasa 40 5 N• EDI 50 N ST. A PN 'F/36 66 !o SUITE' BU83t11138 Allow <br /> Cm 5 Toc K-Ta N STATE za+ 176 Z.O 2-- <br /> BOAM Of SLVWrMM DA,00. t,m"M Cott KeP1 K" <br /> Us"Ad*sss IAPPMIIT,Snw/}ogp•Aellwr Amt rrtkn arCars of tlW&W <br /> qAS N• E L Z)OMLO ST, 4777•• )07 7y LkE <br /> Main°Ad*—`xq' 5.70G470 N STATI <br /> stn Cow AMP 00M1wwr, <br /> TWRa PARTY 2MUNO INM Omplateff BHH P /sOMWVniftmProperty Owtw orFacINty Opwator Idendflod above. <br /> &M M O MAta AbwA)om orCan Of tgodla'rol JO 1� 1 u 2 N sti P b- <br /> raUV Add'e.a I o5,...}p (9 o /�5 r G 44 LA--o t Z3 <br /> Cm A.,r'Lt 7jj coy"0 V Iq v1q '!�v�O STATE � St 1 - i u <br /> i f forlNs and ctwg" OWNER FACll1TY1BUS9 m Tmow PARTY BWNo <br /> 4 the andenigned AppUnst,certify that 1 atm the Owrn,pprow,or.4whorct4.4gear of this Busleess,and f admowledge that all PaawrFEFs, <br /> P&ULTms,F-vFo&cEmLN-r 0wGzs andlor flonur CKueEs atsodated with this optndon will be billed to me at the address Identified aban as the AccouNT.{OQIEII for tbts sits 1 alsocertify that <br /> all informadom provided on this application Es true nd correct;aad that tU regulated activities will be performed in accordance with all tpptinbia Stiv JOAQLCt COL^.fIY Ordlnance Coda amdlor <br /> Standards and STATS aod/or FuutAL Laws and Regulations_ As the uadersigned owner,operator,or agent of the property loured at the above ficWty,`dta addrem 1 Ytrebr authortre the reksx of <br /> arty and all malts and environmental tuessment taformAtion to SALN JOAQUIN COUNTY EMIRON'MEN'T.AL HFkLTH DEPARTltE.1'T as soon as It is ava2sNe and at the samf time It is <br /> provided to me or my repruentstba <br /> Tfiii6AA NA66�- TAxiu:� <br /> i3aala 00- o.e. <br /> ane Mf*AtVN---1 AnouxT PAjo oATI OF PAYWMT I PAw9110 TYrt Ream 0 Cat.Ort P Rtsouta BY WoaK PUN P! <br />