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San Joaquin County Environmental Health Department <br /> DA7El_ ' )J MASTER FILE RECORD INFORMATION MFR GREEN FORM <br /> 6 7 I SITE MITIGATION& LOP <br /> SHADEDAREASEDREHOUBEONLY OWNER IDM CASE# UNIT IV <br /> OWNER PILE:COMPLEM TMEFOLLOW7NO PROPERTY OWNER/NFORMATION.' CNEvirm OWNER Q#pgENfgroNngexyfW END <br /> PROPERTY DWNERNAM! ()0 1 <br /> FInt MI Last PNoNe NUMBER <br /> EUamm NANI imaA LADDREss <br /> OwraerHome Addntla <br /> WADI w�o;t s�, ,^set S� : <br /> Sf�cfog BTABr LP <br /> Owlyr Melllne Addrw <br /> Mallhrg AddrasaI Bbm lip <br /> COR-RATION INDIVIDUAL❑ PARTNMI-Iip❑ FED AGENCY[-1 DmERO <br /> Sfra MmcAT1oN_ENVIRONMRfrAL AEpBmxuPM_VOW MARY CLC11rf V►_W ATQ OOAVTY_HW Pt►ESJN I INvzEmcAT)ON_LOP_ <br /> FAaLITv IDM INV# ACCOVNTID PR#AAW A"GNEDEMPLOYEE LEAo AGENcv:EHD_RWQCB DTSC_EPA_ <br /> A�00 Doo 0 63 T—,7-j <br /> COMPLETIFTHEFOLLOW/NO BUSINESS/FACILITY/SITE AfFORMATJON: <br /> IS this a NEW SUslness LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YEe ❑ No ❑ <br /> Is this an BUSTINOBusiness LOCATION buta NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUMNEWFMItT l8S NAME <br /> , r <br /> SnlABORla6 30/ SUITE# BUBINMPMNE <br /> n <br /> Cm YaL k&, BTAi€ SJP <br /> tdtuRDOPSUPeIWlwngsmlDr LOCATION CODs KEPI KeY2 <br /> MAlibgAtldtaes NO/fFERENr#amPapc; PAddrvea AaerWon:tarCAla Ortoloftra / <br /> Malfling Addrosa City STATE LP <br /> SIC CODE 11 API# ComNENr. <br /> THIRD PARTY BILLING INP03 Complete if Billing Party is different from Property Owner orFacillly Operator idenbftedabove. <br /> SuswEss NAME Attention:arCam Of(oloffie Yf. <br /> MAfling Address of r C /a PHONE JV 493- 03,,r-e) <br /> Cm Sr JE TJP YyJ 7 <br /> �Dm//MO•Amw�s TorfMsandohareef DINNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND CGMELIANEe ACKNOWLEDGMENT: 1,the undemigned AppcanA certify that 1 am the Orvaer,Otnomor,or Audsarfaed Agent of this Holmes,Bad 1 acknowledge that all PERNIr FEES, <br /> PENALnas,ENyofium£NTCNARGES and/or HOOELYCNARG£S mociaeed with this operation will be billed to meat the address identified above as the ALYOONFADOREEr for role site. I also cerdly that <br /> dl information provided on this appliration is true and.,,;and that all regulated activities will be performed in accordance with all applicable SAN JOAQU IN COUNTY Ordinance Codes and/or <br /> Standards end Srele and/or FEDEML Laws end RegWetiom As the undersigned owner,operator,or agent of the property located at the above facility/site addrear,1 hereby authorize the reline of <br /> any and all renulU and environmental aaaement information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM u soon as it is Available and at the same time it is <br /> provided to me or my repraenmdve. <br /> APPLICANT NAME(PLEASE PRINT) L.rLr Ir/ S�iN SIDruTu� <br /> TITS L fI.NH TA) l s3 y�oos" <br /> mvetl a Date Aaeomm Glace Procesalrg Com iotas eY ,j Dab �y <br /> SITE MITIOTLTION Amuw PAID DAmGFPAYMENT PAmENTTYPE RECEIPT# CHECK# RECEIVED BY WDRR PIAN PE <br /> FEE:f B B. � 0 <br />