Laserfiche WebLink
San Joaquin County Environmental Health De•ment R-2m IT <br /> DATE MASTER FILE RECORD INFORMATION f MFR" OREENFORM <br /> J . . n- / SITE MITIGATION&LOP <br /> etaneDAaee9 Frre EHO O OWNER IOP 931S- OAEEN ooap L1 UNIT IV <br /> OWNER PILeICoMFLEYE TH£fAOLLOWJAAO PROPERTY OWNER jAroRm170M: ONwmr OWNER Oegresom" mo �ETID / <br /> PAOPFATYOWNERN-,1 HLNry P ( )gge-.-0965 <br /> Find Mf Last PHOtm Numm <br /> BUaNEass Nape IDIKULADO ®6 <br /> RO-Ls� A11rRn" (i Lbber Co 2v.C- p= v0ro\e amP.Jtf mh-CO <br /> OwesrHorma Addrses <br /> ,Z 17 <br /> city <br /> BTAI! ZIP <br /> aCoHdre.e, Cal,'{ • �U , Fr����- 9�sg � <br /> Owner slating Addreae <br /> P.O. 3ox d-ISa <br /> M.ninaaddre..aty <br /> �/ GFS 95 '7�-0YS0 <br /> Coarowenox❑ IxmWomLL'rJ PARTMERSHIP❑ FEDAGENOY❑ OTHER[] <br /> effB MITIOIETN7N_ENVIRONMIXTAL ANBPPMBM VOLDNfARY GL"wP_WATLR QUALITY_NOW PIPWM INVOMMATiON_LOP_ <br /> FAaun IDP INvs AOOOUNT ID PR OR Aea1GNeD BMpa.oree LPAnAoeNtA':EMD,Z(JAWgDs_DTIlO^EPA_ I <br /> Llt (o(0 3�1 7 v 3�8g( JGg <br /> FACILITYFILE CaMPLEW11H£FOLLOWN0BUSINESS IFACILITY/SITE/NFoRmA71oN.• <br /> Is this a NEWeualness LOOATION nOt proviously roaulaEed by the ENVIRONMENTAL HEALTH DEPARTMENT? YEe ❑ No @I, <br /> Is this an ENIPTINO Bueineee l,OCAnON hula NEW7V_PE2ofregulated Buef`n_e_nSi Yes ❑ No 211 <br /> BWINf88IFAOINTY191RNANe 4zo—L,l <br /> BNEAtessms f� ourms BDSMaESPHONe <br /> 4 LS 3 o W ua L:Kv�2 (�n a c� ;Lo - 6 q&S <br /> Om Tor nP C./-� 95 �g-OYSO <br /> BRIROOFBUpWVIBOR DI9IRIQf IACAROHCAOE KEYd NEYP ' <br /> Malikp AddmsNDIFFERENrfe FMIV*AddMM Adontlan:"Con,Of <br /> fepf/ansl/ <br /> NhIEng Addrems ORy STATE ZIP <br /> BIO GODS APNP -cJG OOMMNM <br /> 2,5L3•*;.16 -33 z 9fr/�C t j �9QcdE4S <br /> THIRD PARTY BILLING INFO? Comp/eta If BIIIIng Party&differentfrompropaqy Owner orFaGlllty Operetor IdentlNed above. - <br /> BunxesaMAMe eNVf2*"V AtterdlowarOera Of fopNwnp <br /> MAllhtp Addross �. 'V - / PHONE <br /> "/S <br /> Om roo r_Ke. ernre�z ZIP 53oIC <br /> ,J3Vf <br /> !Grlaes and charges OWNER FACILrrYIBUSINESR THIRD PARTY BLUNG <br /> DILLMO AND COWLIANOE AmolvilmomENT: I,dlt uodvdgnW Aypikanh a"dy thatl Am lAeOman,00rrvbryorAnldm/udAgmlaf Wa Eueluea,andtorlmorvledpulut se PrAnnTF2sr, j <br /> PrnHn24,EN£OrtrrnreATCNAAGes anNor NOUAtTCNAAcesoaaoahLLW Ads tlJe opradoe rviU he LiUeddme al WeaddmsWenHRW abovem WeAtmfmTAnanexr Porehb alta laiao urtly that ' <br /> ON Warmadon proVlded on this appU"xun Is Irue and rarre"/and?hat oil regulated aC64des rvdl he performed In erwrda lm with all applI.M.SANJOAQUMCouNIY Ordlnase Cad"and/or <br /> Standnrd.And STATE eadfor ptnatuL Laws and RedulednnA N the underdpped orvmy operadr,or REant of My paperry lorand at the above fedary/site oddrea,l hereby amharlu the release of <br /> any end all--Uta and eeMmnmendl euessrnent Infarmadon rm SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT AILTMMT n saom as It is awDANe and at the same dme It is <br /> proNded d me ar my repretenaNve. �- <br /> pPPL10ANTNAME(PISnsEPWlf» eanpe JQI^Y f n SIGNATURE <br /> TITLE tclA ta.10' <br /> 7A%ID11 r� <br /> A ved DaAamau OMee Praawalna Dom ladtl pay <br /> Data ��1/ z <br /> BRE MIT��IG-ATTT10N AMOUNTPND DATEOFPAYM/ENT PAYNENTTYPE 11WEIPTP OHECHP REOEIVBDBY WbRR}NpeANPE <br /> P <br /> FEa JrS Y, S �t�{IZ (S/'� �iQi ^ ISU <br />