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0 0 <br /> San Joaquin County Environmental Health Department <br /> DATE 1 b _ 1 (,[ MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> /� A [ SITE MITIGATION$LOP <br /> Lm:^s`Ae[u E➢N ENO CaEOxLY OWNER IDS T'-shoo 71/ /6�7 UNIT IV <br /> OWNER FILE:ComPLE7,EPROPERTYOWNER/RESPONSIBLE PARTY/NFORMnnON, Owcarr�OWNER Cuxe*,m—r-1w'aexnNEHDEl <br /> PnoriarYOnuEn Nasia _ Vl 06 <br /> FYer w I teat pI NmlrEol <br /> Busutow,NAYS C44cHaui.Ascaawa <br /> n <br /> Owner Hones Addreas <br /> city J ✓1 11 , BrATE ,Or l <br /> Owner Making Addreee S <br /> Mallllg AddraaaClty Stat, by <br /> ❑coa naanaN Cl INONIpwL ❑PxaTNEaMv, OO.'EIUINExr AGENCY ReePONsiutE PARir ❑Great <br /> SITE MITIGATION)(ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FAcx"ID$ INYk Aeoouxr ID PROIRON AaEl�a,x/���00,FILr�aME LEAO AOEnw:EHD_RWQCB_DTBC_EPA_ <br /> $ i� /7 S Y <br /> FACILtTYFILE: COMPLrTEBUSINESS ISITE/PROJECT twoRMATION. <br /> Is tNs a NEW Protect LOCATION not previously regulated by the FJrvIRONMENTALHFALTH DEPARTMENT? YEa ❑ No%�r <br /> Is this an Mamma Pralact LOCATION but a NEw SCOPE OFC WORK? p Yn 0 No, <br /> BGEINFJWFAourfY191IF1PaOJEOT NATE —Moil <br /> BRE A0011Eu IPROIECT InOMpN I 1 I /A�I� (� SUITE$ samese PHONE <br /> Clrr t Q_ <br /> (A7 <br /> 7 <br /> ZIP <br /> BOAA00F SUPERYmaa Dlsrnmr LOCATbN COpE IrEY1 KF2 <br /> Ma]IIIg Addmaa ifV1FFEREA7fvm FacII&Addrrmaa � �//� �I r� G /jv C ABentlon:arCaro Of(opHonal/ <br /> Melling Address City _I�V� V�T ' Te zw <br /> slCCooE APNk CaumE .. <br /> THIRD PARTY BILLING INFO' Complete' Willing Party is diffemntfrom Property Owner orResponsible Party identifiedabove. <br /> Bume,,NAM: J/,\._ 1JQ✓&e — U oV, P Manton:o,C.Of(npNonal) <br /> Malllna Addroaa �L n PHONE <br /> Clry 7 1� STATE LP / <br /> AAmLa¢Ame�T forfeas and ahargea OWNER FACIIJTY1BUsINESs THIRD PARTY BIWNG <br /> BLLmo Arco COmrL1ANCe ArKNowtroeurxT: I,theuwltoiV dAppliant«rdfy that Iwm the 0.cr,Opv ,ARA.*WAga,m Rap...,Pary and 1adermhdge that all 1 n,Fier, <br /> PFlGLnEq ENrancrAravr OuacEf aRNorllosALYOuncu ftmodatdeith"prolrt eik be UW to meat dlemldreae Makeed abase m lbw AcEeuaTAnnnm'ror"Ilto Ia60mrdry11M1a11 <br /> inraaMtim providod an ffih appdnfim u true ax1mr ;and dui lU rgrrlatW and idn eitl 4 performed to wo ham eilb W oppdcaMe BAH JoAww CouN Onlimort,CWo aWem <br /> Blandanlr and STATE wWor Frocur,taws aW Rqubdom, As the uW enipud OMnrr,Operator.AWlmdmd Agent or Ropomible Party ror the pmjort ImeIW ahare wader rullity)Wc addrm,l <br /> hrmby auCmrne We Weare oranyml aN rdt%reporu,and uhermiroomental Avevaamt iororanHen to SAN JOAQUIN COt1NY EN"RON1IEN1'AL HE LnI DEPARTDIENT"too.u it <br /> if aeaflahle W at the alma time it a pra'idrd to me or my mprmxtbfi,n I <br /> APPLICANT NAME(PL wPaw) �.'1+A K) 24 L)4_p '(� <br /> Trn.E erurArGAE <br /> �I TAx ID II <br /> f�s�rs,-�n,� �N�-I�FFt� (0600y3L� <br /> Dr. aama M. w or Data <br /> BIramaw ION ANauw PAIa OATEOFPAYNENT PAwwwTYPE REcEWrk CHECKS Rwswa BY WOm l"PE <br /> F�'9 3505 <br />