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San Joaquin County Environmental Health Department <br /> DATE Z 1 i « " GREEN FORM <br /> MASTER FILE RECORD INFORMATION MFR <br /> ---- — _ SITE MITIGATION&/rLOP <br /> $HAPF-Q A9fA1lLFQR.IiI UZIE-ONLY OWNER ID# CASE# UNIT I Y <br /> OWNER FILE:COMPLETETHEFOLLOWING PROPERTY OWNER 1NFORMAwN.' CHEcK1F OWNER CURRriiaYON EWITH EHO <br /> PROPERTY OWNER NAMErl 1�{r �p'. /zz) � --35 <br /> First M/ L Last PHONE NUMBER <br /> BOSINE83 NAME ` I E•MAll ADOltEssa`CL t1.5 QYIA (.l( <br /> r✓✓LCl��1 �(11V1 GI �5;,t_.fd. �Ji l C ai�aiJl-L <br /> J t{@T�!^ �1�.LQ111 <br /> Owner Home Address <br /> city STATE ZIP <br /> Owner Mailing Address r A Y <br /> r a1" <br /> Mailing Address City (� 1 gtafo ZIP <br /> CORPORATION Xl INDIVIDUAL❑ PARTNER4HIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT AOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FAcam ID# INV# ACCOUNT ID PR#/RO# ASsIONEO EMPLOYEE LEAD AGENCY:EHDRWQCB_-DTSC EPA <br /> FACILITY FILE COMPLETE THEFOLLOW/NG BUSINESS 1 FACILITY/SITE 1NFOR4f_AT10_N: <br /> Is this a NEW Business LOCATION not previou*regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes ❑ No <br /> IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YEs'yd No ❑ <br /> BU8tNE88lFACIUTYISrrE NAME 1 '- <br /> e. V 0 . v V Edat m i Yl I - 1a v{CQ f <br /> SITE ADDRESS )?W/lrJ'4Jl_.-lt 1 rt ,t Ave_ <br /> SUITE# BUSINESS PHONE <br /> CITY �. STATE ZP 175-2 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 =K-2 <br /> Melling Address lfOIFFERENT from Facility Address Attention:orCare CN(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INPO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME 5�0n \)1 Attention:orCare Of(eptlofwo cc)AD(-nPfi4 i 5 <br /> Mailing Address, Y l ' PHONE <br /> t tit d Do iu) oU <br /> CITY STATE ZIP <br /> Glhv%lcA <br /> AFCDLdIzAaDmESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> HILIANG AND C'.OMFIJANCD1,110T: 1,flit undersigned Applicant,certify Ihat 1 am the O"er,(Operator,or Authorized Agent of this Business,and I ac lumwlydge that all PERAMTPYlES, <br /> PENAL.1TES,ENtYMCFAGSA'T(71AN6E.5 and/or Hoo1u.r 01eR61•;v associated with this operation will IM billed to me at the address identified above as the A(C'oMi AUnN6'.a'for thio site. 1 alae certiry that <br /> all information provided on this applitalion is true and correct;and that all regulated activities will be performed in uccordance with all applicable SAN J04QIIIN COUNTY Ordinance Codes und/or <br /> Smndards and 5'rAIT and/or FEDEaAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and tovironmental assessment infurnmtitm to SAN JOAQUIN COUNTY ENVIRONMENTAI.IIF.AIa'II UBPA R'I'M F,ti 1'as soon as it is available and at the same Time it is <br /> providrd ionic or my representative, t/�' <br /> APPLICANT NAME(PLEASE PRINT) -G1,�1,'Y1A ✓V lilt JfC SIONATugE �� 1. <br /> TITLE ^ TAX 1 <br /> 64K U <br /> Ap oY*d Dab Aocountlnfj Office Pr—sslN Completed B Dnte <br /> I SITE MITIGATION AMOUNT PAID DATE OF PAVMEfff PAYMENT TYPE RF.CIiIPT# CHECK III <br /> RECEIVED BY i WORK PUN PE <br />