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San equin County Environmental Healt4partment DATE I MASTER FILE RECORD INFORMATION "MFR" GREEN FORM SITE MITIGATION & LOP sHADEDAREASFOREHDUSEONLY OWNER ID# CASE# UNIT IV OWNER FILE:COMPLETE TNEFOLLOW/NG PROPERTY OWNER INFORMAT/ .,%TMVNER CURREMrcrONFALENow EHD� PROPERTY OWNER NAME MdAJr�Le &e,Son .4065' < FiMt ` ��rr�� Ml /� /I Leal 1 - PHONENUMSER BUSINESS NAME 1� {-rs pJ'+'tO rY JtrA Wl N7s VT ,Sl,Arpt SI 'I'� E ILADDRESS DLk, 4.S J /a4vr ca a 6EISOnde Owner Home Address `/A 8 ,50 F, Ro tt, /l CRY �J L 01,ror STATE CA zip J!� G' 330 Owner Meiling Address N £Av, v, QranPl DLA 7 eSfiAQ�, Sv mr{11 a �} Si.r• -TOA.2" W, 4065 9 16B /lttb, Flinn Mailing Address City P, o , g Ox 6 6 coo/ 5-l-O r k+70,% Ste" CA 9 S Z 9 6 - 01 CORPORATION 11 INDIVIDUAL❑ PARTNERSHIP❑ FED AoefacY ERY. OTHER❑ SITE MITIGATION_ENVIRONMENTAL ASSESSMENT I VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATIONLOP LOP_ FACILITY IDK INv# �AccoUNTIDASSIGNEDPLOYEE LEAD ACENcr.EHD RWQCB_DTSC_EPA FACILITY FILE COMPLETE TNEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION: Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No 19 Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No 09 BUSINEssIFACILRYISRE NAME Sm ADDRESS V J�J�O J�I\r �� / SUITE# B .EESs IgNE i q 39 -9V C" f•_1 p/-!I STATE Z" t) 5330 ISOR BOARD OFSUPERVDISTRICT (lLOc11,.TON CODE KEy1 KEYZ Meiling Address KO/FFERENTrrem FaaftAddress Attention:orCare Of(opbbrsao Ajfn s £nv, SCrv, Rr•...e% DLR 1nt1.W, Sv f .+ 5" Shat vr� Er f I/OGS 61 Ibo $IC?*F1aor Mailing Address City /1 f j_ STATtA ZIP gS'Zgd—f/3 J�`O Combe. nen Ui SICCODE APN# COMMET: N THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. BUSINESS NAME U 1D C> r Attention:orCara Of K (o/pfAwm// / K K.ro2 S Mailing Address Z 8 IA w D S D r, 5�-e.. 30� PHONE ,i /O) lJ/ �.9 - f\.Z,0 -4 I CITY so,C/ra Vry'f n M STATE CA \ �b g SF 3 3 BGQQUMrAaawM for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owwer,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERMIT FEES, PENd TIES,ENFORCEMENTCNARGEs and/or HOORLYCHARGES associated with this operation will be billed to me at the address identified above m the ACCOUNTADDW.y for this site. 1 also certify that all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or 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,I hereby authorize the release of 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 lime it is provided to my representative. APPLICANT NT NAME(PLEASE PRINT) `/A}YvvK. 6 A,t'6 r42 SIGNATURE TITLE s,I 4 Setrr 1 y Cn Grl �3 f TAX ID# g y _ 3 0:7 3 s y Approved 9y Date Accounting Mee Processing Completed By Data lc SITE MITIGATION Amouw PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORKPLANPE FEE:to-