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San J juin County Environmental Health _ lartment <br /> GAS S A <br /> MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADED AREAS FOR EHOL cA8E: <br /> OwLy OWNER ID# UNIT IV <br /> ONIMER FILE:COANxETB rwFoLLowi•A llg PROPERTY OWNER/Nfolwe4rioM.• fa+EcxIF OWNER CuRmwnlrowacEWTH EMO <br /> PROPERTY OWNER NAMEMV v 1✓ � 3tS�r <br /> First M1 Last <br /> PHONE NtweeER <br /> Stamn NAME <br /> 746-44 W t4,4 G T ai G a. ' Gµ PAAAtT xv' <br /> 101 Rlw~ m.Addrw <br /> STATE ZIP <br /> owns 111.r1r,g Addrw <br /> Ad*an City <br /> svt�4 ZIPa6 a <br /> CORPORA INOMDUAL❑ PARTNERSHIP❑ FED AOENcY D <br /> OTHER❑ <br /> tin:fl*Tt&AT10M—ENVIRONMENTAL AsaffesumaxVa„uNTAKY CLRANtlr—WATER QUALITY—HW'iPsuNN _ <br /> FACILITY ID t INvA AccoumT 10 P�RAWRO a! ED EMPOYEE LLEAD AOENCY:EHO <br /> �Q� AssioN <br /> 12WQCe—orac_EPA_ <br /> FACIUTY FILE COA NI ETE rNEFoLLOrW/VG BUSINESS/FACILITY/SITE/An-wmArronf.• <br /> Is this a NF-:w&mines LOCATION not Previously I SWA tted by the EWRONMBdTAI HEALTH DEPART1kEfM YES C3 No <br /> Is this an Extarma Business LOCATION but a New TYPE of rnguk ted Business? <br /> YES ❑ No <br /> lF <br /> £ssAcutrY/SITE NAME F v7u7z� ��z e� <br /> o <br /> F�A�R r�Ci � 14 G o <br /> &tEADDRESS sT��-a' �. 17?- <br /> 76Y-7 PA61 Fc AVF- SUITE= Bust►-ft PHONE <br /> CITY STD GKTa �v STATE <br /> C�4 t3-2-z)7 <br /> BOARD OF SUPERYtBOR DWTR1CT LocATtDN cDOE ,�E,-, <br /> ICEY2 <br /> MmWV Address MD✓tFS?Ei1►Thsw FsailllyAduhsar Atbntion_crCara 01(AoCwrsll <br /> Msillrtp Addraaa CRy <br /> STATE zip:� FON <br /> C� APNI► N <br /> TNtRD PAnrtf alio INFO: Complete d Billing Party is different from Property <br /> v <br /> t NAME Owner orFaClly Orator identified above. <br /> TGA O� Ati..,et....• .... _... <br /> IW/ktg Addreaa <br /> Z-5 Gti1A G/Rc-� PtaNE o <br /> CITY 9 <br /> rt ol�ra�et' STA ��ns � <br /> u&m'�° fees arld ol+s►aes OWNER FACIuTY/BustNE$s THIRD PARTY B1 <br /> BILLIV SNDOMPIJ� wL M �-r 1.the undersigned Applicant,certify that I am the Owner, 0 <br /> PewU nE EnFr>RctxEvrCrr urcts and/or HrxruTCtu ecss associated with this o fir° or Anthorfird Agmr of this Business and 1 acknowledge that all PERMIT FEES; <br /> Aeration will be billed to me At the address identified above as the:j]Lot?yrAD/NLFjT for this site. I also certify that <br /> All information provided on this application is true and correct;and that all regulated activities will be performed in accordance with an applicable SAN JOAQUIN CtWNTY Ordinance Codes aod/or <br /> Standards and STATE and/or FEDERAL Laws and Regalatiom As the undersigned owner,operator,or great Of the property located at the a <br /> nay and all results and environbove facilitv/site address 1 hereby authorize the release of <br /> provided to me or my representative- <br /> assessment information to SAN JOAQUIN COUNTY ENVIRONMENT.{L HEALTH DEPARTIMENr as soon as it is available and at the same time it is <br /> ve_ <br /> APPI.ICAN{TNAME(PLEA9EPRIHT) � v�A <br /> /' A' 1/ SKiNATU.E_j <br /> TITLE fly�7• � ZI'6ZT /"A444t69ZTAX ID f <br /> By Dat' AccourdingOtrtn.ftaosaskM CWWWW ev nae, S to <br /> SITE MmoATtON AMOUNT PAID DATE OF PAYMENT PAYMENT TYPET <br /> ECEIPT <br /> FEE:; CHECK REc£NED EY WORK PLAN PE <br />