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San Joac, _ I County Environmental Health Der -tment <br /> DATE �j / LMASTER FILE RECORD INFORMATION "MFEt— GREEN FORM <br /> SITE MITIGATION& LOP <br /> SHADED AREAS FOR EHO USE ONLY OWNER IDM CASES -�Ij/#)'f.. �1 A](A UNIT IV <br /> OWNER F1LE:CDAwxETrTHEFouowrw PROPERTY OWNER/NFORMAwN.• CHEcx1F OWNER CURRENTLYON FILE wtrH EHD 10'" <br /> PROPERTY OWNER NAME 'TR If (5&) Cts/..,3 el <br /> I I First MI !/ Last PHONE NUMBER 3f <br /> (� <br /> BUSINESS NAME E-MAIL ADDRESS G bR15 PAti' IT L <br /> T foRtil A GT T o/ Gam. �fi ;l.cor, <br /> Owner Home Address <br /> ChY STATE LP <br /> Owner Mailing Address 13119 A4 / ' / k/A <br /> MGMV Address CNy A�A F� �RJ,v6 O ",,:"A z'p,,v 6 7 a <br /> CORPORATKNI�O INOWIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> INR Mma►TION_&MRON1111111111INrAL Asa■splerr VOLUNTARY CLEANtrr_WAT=QuALrrr_HW PlrwNE Iw m77mnoN_LOP <br /> FACILITY ID M INVi AOOOUNT ID F43WRO MASSIGNED EMPLOYEE LEAD AGENCY:EHQeV�RWQCS_OTSC—EPA <br /> FACILITY FILE CoAIPLETE rHEFOLLowliNG BUSINESS/FACILITY/SITE/NFORMAnoN° <br /> Is this a NEw Bushels LocAnoN not prevlousy regulated by the ENv1RoNMENTAL HEALTH DEPARTMENT? YES ❑ NO <br /> Is this an E)asnmo Business LOCATION but a NEw TYPE of regulated Business? YES ❑ NO <br /> BUSINEaWFACILITY/SftE NAME 7--11 r Kow ���/ ��� 60. <br /> 5 ,L7 /(/-O� � •O. /I� <br /> SITE ADDRESS 7,KY 7 �,4 /� <br /> GJ A✓E. �' SUITES BUSINESS PHONE <br /> Cm S?o GK Iro STATE <br /> IP <br /> CA o7 <br /> BOARD OF SUPERV190R DISTRICT LOCATION CODE KEY11 KEY2 <br /> Mailing Address NDIFFEREWTthamFacfrtyAdl Yew Attention:orCare Of(opdfomi) <br /> Meiling Address City STATE ZIP <br /> SIG CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAMEAtherrllOn:orCars Of�aI-p"W) <br /> /�G >� Go4voCO PIWu <br /> MtWMtg Address ! G v r ^ll I f)GLC PHGNE 05 i /e—/Z/7 <br /> c,ry '*b�na1 PA'S K11 TE /P S <br /> AcpqLwTAqqmw for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERMIT FEES, <br /> PEN.0 nEc,ENFVRcEMENT CHARGES and/or H(7l.'RLYCHARULS associated with this operation will be billed tome at the address identified above as the AmouNTADDRM for this site. 1 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 all applicable SAN JOAQUINCOUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL laws and Regulations As the undersigned owner,operator,or agent of the property located at the above facility/site address,1 hereby authorise the release of <br /> an),and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) 13 b� G 2_5 EA--- SIGNATURE — ----- <br /> TITLE 5 F. Q <br /> • ppJ L TAx ID# <br /> !Moved By / v`Date Accounting ORloa Oorn~B i Date <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT M CHECK M RECEIVED BY WORK PLAN PE <br /> FEE:; �� 4 <br />