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San Joagain County Environmental Health L�,artment <br /> OAS fZ/Z3/// MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> �- _ SITE MITIGATION&LOP <br /> OWNER ID/ I 4dACf10jDj411t5 UNIT IV <br /> omm FILE:CoAokETETHEFoLLowlAAG PROPERTY OMER/A7Rwnow CHECK or OWNER Cum mrnyo ni-Ew rm EHD <br /> PROPERTY OWNER NAME R If W 86 f 1,` Yom+/ '?Z/—3M1 <br /> First MI Last PHONE NU I / /� <br /> Bumems NAME E—L y►V PwclArTgeil <br /> 543 T "L-lf J 6A5 GT TAIF <br /> of t ;l.Cor+ <br /> Owner Homs Addr eas <br /> CRY STATE IIP <br /> OWnar 11 111 Addressi tS WA <br /> MYNg Address`:11P /i•� A r ads <br /> FF- PRIG '406-70 <br /> CORPOR .T.( INWOUAL❑ PARTNEttSMP❑ FED AGENCY❑ OTHER❑ <br /> *M MI'n6ATION_1111IVIRONwfrAL Awa ,2(_VOLUNTARY CMANW_WATM QUAL rY_"W F4MUM 1Nvwn""M <br /> FACtLm ID f INvt A000umT ID I�RO i Asst E EraPLO LEAD AGENCY:EHQX—RWWB_DTSC—EPA <br /> 37 tar+ <br /> FAGILI Y FILE COMIKETE 7WFOU6WAOG BUSINESS I FACILITY I SITE/AiFORManay.- <br /> Is this a NEw Business LOCATION not previously regulated by the ENVOWNMENTAL HEALTH DEPARTMENT? YES ❑ No 19 <br /> Is this an EXISTM Blrairess LOCATION but a NEw TYPE of regll med&wkNm? YEs ❑ No 14 <br /> BUSlftESSffACKJTY1SITENAME7// KAbR TAPOIL Gv S;�o r/Alo. /1Z <br /> SREADDRESe T�Y 7 f,46I 1/ A �5. SURES BUSINESS PHONE <br /> CITY sTo(!C Ta^/ V <br /> GASTATE ZIP 7 <br /> a <br /> BOARD OF SUPBWV OINMUCT LOCATION COOS Keri KEY! <br /> MIIrI�. Addor.� <br /> ess aevrftmF&� w sn <br /> AomaAmuon:or Care of(gp&vn ) <br /> Me"Ams Cft STATE IJP <br /> SIC CODE APN: COMMENr: <br /> T11111111111111 PARTY 011AAM IWO-. Cove WWO 1f Wing Party is different from Property Owner orFacft Operstw identified abovle. <br /> BUSMIESSNAME /' Af wt1kin:arDam01 aodra►ad1 <br /> /�"rG tT Go�Voco P /GU <br /> MaMNg Address <br /> SGv fhN/ r-JUZ PHONE Y N-1217 <br /> CM ,*bA11XX9P1 PAR K STATE <br /> % S <br /> AlaxlywAamm for fess and ohmrgas OWNER FAc[LITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOwLEDGM&CT: L the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERetrT FEES, <br /> PL'n;tetTFA ENFr*?cEA'EATCHARGE4 and/or HOURLYCHARGI:T associated with this operation will be billed tome at the address identified above as the A(TOCMADDRECS 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 all applicable SAN J0AQu1N COUNT, 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 authorize the release of <br /> any 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 3��PRINT) G��u ��(� SIGNATURE <br /> TITLE 5!v . P!?v TAX to <br /> 2- <br /> SITE MmtaJ,nON PAID DATE �OENT PAYMENT RtnElnr fT CHE�� R IQWORK PLAN PE <br /> FEE: f6q I <br /> C <br />