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Sa oaquin County Environmental Health De•ment <br /> DATE MASTER FILE RECORD INFORMATION"MFR" <br /> GREEN FORM ( <br /> OWNER IDV OABEY <br /> SITE MITIGATION&LOP <br /> UNIT IV <br /> OWNER PILE:COMP[ETF THEFOILLOW/ oPROPERTVOWNt:KfA WNAnO,v,. oxmxerawHERouxxmpnyaxruvHmEHD� <br /> Flrsl Ml <br /> PROPFATYOWMERNAMe HfNre <br /> J &V Wc� ~} ( )S36-oa6S <br /> BUEIxEt1 NAME Leal PxONe NDNDER ' <br /> Rd-Le" Atrn- • (Z,b �o ZY c- E R.ADo E/1 <br /> OMTI1r Hdna Atldnn / 4+T'1 T("D Co�oafQMCK Cppr.(p I <br /> Ob. <br /> MATE ZIP <br /> tivnur MllBnD Addro11 <br /> Ro. $ox IlSa <br /> MIdINg Acidness CYy <br /> firYa,IL M� <br /> ZIP <br /> ,_,/ 95 -I�-oYSO <br /> aonroRATpxO IxaaouA[L•U N �nON,_LpPO <br /> PgRrOMAR NEAemH❑ FeopoExor❑ <br /> arEBMITIpA7pN._EMPIGNMWrALANBtlMENr VOWNTARYCWNDP_, gE WA7 <br /> 4aW"—HWPIIMaINR 1 <br /> FAqurvIDY INV# Aaoouwlo <br /> 53epg�� A1elDxeo EAnl.oree LrADAaeNRiy;EHD^gy/aCR_DTRC_,EPA <br /> FACILITY FILE COMFLErE rHEFOGLOWb 190USINESSlFACILITYlSITE/NfOgMAIyON.• <br /> Is fhlaa NEwBuelneeu LOCATIOM nolPreviously repuleted by the ENVIRONMENTAL HEALTH DEPARTMENT? ,_,/ <br /> Is this an EXISTING BusInts LOCATION bola NEW'fypE RNfeauleled Business? Yrs LJ No &r <br /> aRkIK®ufFA011lYYAI1TENAME /T Y� ❑ No s <br /> 20-Ldb P11 urs A 1 bSer <br /> SCol <br /> negpDR�e cY ` <br /> o O W QS? LeNV\� �0.—k 91x1EY BUEINE118PHONE Q <br /> C" T ;Ao l� <br /> zP <br /> BWROOPBUPERVIIOROIBfngf or <br /> LoonnoxCouE KEyi <br /> KEYt <br /> Mallfrq AddnEe NOlfFiREAITfiwxFiod/ygddwae <br /> Attention:w0un 01(epYoxdJ <br /> Manna Add vaso y <br /> BTAre ZIP <br /> SICOoCE APNN <br /> COMNMIn <br /> THIRD PARTY®uuNIsIHPw Comp/etelfbilling par(y/sd{/lerentiromProperty 0wnerorFaDllity0 Bratnrldent/Aedabove. <br /> BU11NE61 Nane <br /> �/�(/���� Atlatdlon:w0an 0/(trpYwAeq <br /> Mellbg Addnq /� / q <br /> Cm s' r O v PiV'G Ci/I�iC /!O <br /> /3r00%,p5'rld eTATEwa zip S3oyS" <br /> QaEVfaffeea and Charge/ OWNER FACIIRY/BUSINESS <br /> BIG AND CO UANCEA THIRD PARTY BI.IJNG <br /> --�1 g.S : I,tlm uoJ>ei'ned Applicant,arrdfy hit l.m the Ourn,OpemWry orAelAoriud Agog of Iib Bmiii <br /> PE.wRtrrrs,GN/aAC2T/gxrG}/nRer31mJ/arNouurCxnAers mrvdeUdtdW Rile vpecai{avrvil be Lined to me al Wruddreu lJenH&J obevem lhB.'Int odJ lmklorvledus shote rrEwrA3r, <br /> oil bdormaxon pravldeJ on 140 appumdvn 6 4ue Rod carred;uW thu oil rquhleJ actiriues rvW be pvfervNd In arrortlwee Mlh ell eppncable S.JOA um Co far Rhb este. 1 ell.mrdfy Ihvt <br /> StevJnrJDaoJ STATS aeJ/ar f•4o[ML LnrannJ Reluletlone tithe uvd<relAneJ orvrcryo ermagorx Q u^TY ordMncee Codu and/or <br /> Roy and AR,o,t ,uWe P -tom the prolerry lwond et Rhenbove fednly/eltendd,y I hereby mRhmtre the releue of <br /> nv4rvn ttv,, eueeemevt InformaNen to SAN JOAQUIN COUNTY ENVIRONMENTAL HBALT ARTMENT Ae mon w It n awUAN.end At Ilu tame Hvu it le <br /> Provided ro me or my reprdenroHve. ' <br /> APPLICANT NAME(PLE Fmn» eanneJ <br /> I <br /> /Q I Y 1 n BIONATURE <br /> Taw C? Ace' ctF TAX IF) <br /> A ood DSM <br /> Aaevu OMoeproabdn Cam MMd <br /> SIfE MITIGATION AMGUNTPAIO DATE OF PAYMENT PAYMENTTYPE REOEIpTY 0.b <br /> FEE:, ONECKY ' <br /> REpnvEo eY WdiRKVIAU PE <br />