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• • <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE �I(u 113 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED ARFAa FOR EHD USE ONLY Dart"IDIS CASE# 1 UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CmOKjFOMmjSCUsNNSYeroRFRewnR EHDEl <br /> PTroPE OWNERNAME Lv,Co`e, cm 1Uo (2Cq) 470 1ZOCJ <br /> FIRsi MI LAST PHONENUMBER <br /> BUSINESSNAME /` (2O('. pe C>�l S 1 ` EIMILAODRESS tl�.g - �w rra�—rev L. OY\ <br /> OWNERHOMEADDRESS <br /> 0" STATE LP <br /> OWNERMmuNGADDREES <br /> AMILIN6 ADDRESS CRY > —Skc.0 ar Q.A'V�� STATE CA LPq <br /> CORPOMTION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION X ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FAauTYIDR INVC ADDouNTID PRIVROR ASSIGNED EMPLOYEE LEADAOENCY:EHD_RWQCB_DTSC_EPA_ <br /> FACILITY FILE:COMPLETE BUSINESS ISITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OFWORK4 YES No ❑ <br /> BUS W ESDIFAC IUTY/SREIPROJEOT NAME <br /> �veCcti r. <br /> SITE ADDRESS I PROJECT LOGATK)N �L,77 r` n �fT`tLrY.An F'bN O Sums BUSINESS PHONE <br /> V[C�C'•C. AJ '. TJ� <br /> circ1�16 _\,. ,�� CA nP,52s)� <br /> BOARD OF SUPERVISOR DISTRICT` LODATION CODE KEH KEY2 <br /> MAiuw ADDRESS,F DIFFERENT mom FmLnv ADDIIESS ATIENTON:ORCME OF(OP1/ON41) <br /> 2b c,�aJ,s '1�c eV, Dr VI%CC clo <br /> MAIuNDADDRESSCITY STATE ZIP <br /> Sec c k CA `I6-'s33 <br /> SIC CODE APNB DommawT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAMEZrYI ATTENTION:ORCME OF(OMPANN J C-to L\n Y M" <br /> MAIUNDAoDRESS 35 o IsmTt O-424—`t 37 y. <br /> 52 �lomc4S t� 17r C� <br /> clrY STATE CA q5$3 <br /> ACCOUNTADDRESSTOSENDFEESANDCHIIRGE3: OWNER❑ FACILITYIBUSINESS❑ THIRD PARTY BILLING <br /> B LLNG COMPLMNCE ACKNOW LEDOMENT: f,the undersigned Applicant,certify that t am the Oaner,Operator ADflmnud Asen4 or Relpoomb/e Perry and I admowledge that all P£R n FE£s, <br /> PEN TfEs,ENMRC£AWATCRARGES and/or RODRLYCIGFG£Sassociated withthis projectoill be b9led tome at the address identified above as the ACCOUNTADDR£ss for"site. I also certify that all <br /> information provided on this application is true and correct;and[hat all regulated activities mill be performed in accordance wits all applicable SAN JOAQUIN COUNTY Opnnt NCE Comis and/or <br /> STA s,SDS and SPATE and/or PEDERAL Lmvs and]UGULATIONS. As the undersigned Owner,OpemfaD Anflmz;edAroq or ifs om'ible Party for the projectlocated above under facility/sift address,I <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY FNVIRONAMNTAL HEALTH DEPARTMENT M soon as it is available <br /> and at the same time it is provided to me or my,representative. <br /> APPLICANT NAME(PLEASE PMNT) br\Askv 1n(j,.,�' Sn—TURE'�Ary�Cf',—z+1 V <br /> TITLE iS� E(Z,m TMID# <br /> APPROVED BY DATE ACCOUMINDaFACE PRocESSmDCANPIEIm BY DATE <br /> SITE MITwTON AMOUNT PAID DATE OF PAYMENT PAYNENTTYPE RECEIPTIF CHECKR RECEIVED BY WORK PIAN PE <br /> FEE:.$ <br />