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p" San Joaquin County Environmental Health Department <br /> DATE r�//, MASTER FILE RECORD INFORMATION "MFRI' GREENFORM <br /> •9 `r" -- SITE MITIGATION & LOP <br /> sHAOEoyg.,y gO,lAIt9Js.Y OWNERIDNUNIT IV <br /> OASEN <br /> OWNER FILE:COMPLE7E7NEFOLLOfY/NO PROPERTY OWNER/NFORMA>70N.' Cr/ecrr/FOwNERCtARRFNnvekAk Xn`NEHDEl <br /> PROPIATT OMER NAME Lla.aritu f P^'kl / <br /> 7-6 be J o <br /> Rmf Mt Calf PHONENU"M <br /> sts" /f EAIAILAODRESS <br /> t_ �F Tn�trnA�On4) 4 S <br /> DRa kspeAddressCNN <br /> o J -'{}wPat►`c Zl70ef E. .4✓E� �Cl�� <br /> FsrAID� <br /> t/ STaTEC.4 <br /> �\�.Y1/`'1 ONJterM.DnpAddnp „1 t ^ L �C �,/ Qd <br /> Mailing Addles Opt <br /> I:$ ( A <br /> G �0V1 p �e(14 Z!P 7S3aC <br /> DORPoWTH)N❑ IMDMDUal.K PARINERBHIP❑ FEDADENDY❑ o1 [3 <br /> SITE MITIGATION_EWIRONMENTAL AaeISRR0w_VOWNrARY CLWMP_WATERQDAIJTY_NWPIPEUNEIWdBM ATION_LOP--F= <br /> FAcam IDN INV# AccoMrr R) PAAtRON AsuoNEDEMptoyme Lend AOENCY:END_RWOCB_DTSC_EPA_ <br /> kkl,0LakolMj LA <br /> FACILITY FILE COMPLEZZ'THEFOLLowNeBUSINESS IFACILITY ISITE INFORMAIll <br /> IS this a NEW Business LOCATION that PMIOUGiy regulated by the ENMRONMENrAL HEALTH DEPARTMENT? YES ❑ NOW <br /> Is this an EXISTING Business LOCATION but a NE YTYPE of regulated Business? YES ❑ No <br /> BUSlNEskJFACRRY/SRENIWE l r) T� rn•.jJON1� SA rj [,/0 �a v, <br /> /C 1 Tc/r d o <br /> Sna Aaameas y 3 A 1•y �j r,''✓c grmE# OMMU Pll <br /> Cm <br /> S-�nrit,-kn STATE <br /> A LP 9S9a6 <br /> BOARD OF SUPERVISOR D141AICT /S LOCATION CODE g� NEY1 I(EY1 <br /> Mailing Address HO/FFEREATanm Fac1A1YAddrscs Attention:orCare Of(opfforkef) <br /> Mailing Addr000 City STATE ZIP <br /> SICCOOE APN# GOMYEM: <br /> 11 <br /> THIRD PARTY BILLING INFO- Complete if Billing Party is different from Property Owner or-Facility Operator IdenHBedabove. <br /> BUSINESS NAPE Attarel on:OrCare Of(aptionaf/ <br /> Mailing Address PHONE <br /> COY — STATE IJP <br /> ACCOBATAOORESS for fees and charges OWNE FACILITY/BUSINESS THIRD PARTY BILLING <br /> RILLINC AND CO>IPLIANCE ACHSONICUDa1ENT: 1,the undersigned AVPlicaa;urtifY that 1 em the Omen.Ofreratw,ar AnOrorim/dgenroGhis DusiRm;mtA 1 nekmnledge tlul ell PExvn'FEae. <br /> PEA'A.DES,f:NFONfEAr£NFC/{ueeceand/ar llnlnu rC/LINu£.ra,UOCland\riIIr ILIs UyernNun Will bfhlR<d sa ulfal sM1r adAresY ldenll RedalroVu e9 rve'AnnxssY or he. lalxn certih that <br /> all information proridod on this syplirmiun is live and carred;and that all regulated activities will he perform"in aecmdue{ .1th all v cable SAN JOApms COtmn'OrAi ¢e Codes and/or <br /> SnmdaNsanJ STATEand/or PFDHMt.Lens end RegUlndnns. As the undersigned onner,operator,oregenl of the property loatet at the r<faciliry/sitevJdrm,I herebyvuWo eth<r<leaseof <br /> any anti all results slid en"ronanntal assessment infonaatien to SAN JOAQOI.N COUN.n'ENVIRONMENTAL NRA LT DEPART 'NT as soon as it n available mtd et a same time k is <br /> provided to me or my represeamare. <br /> APPLICANT NAME(PEeamiPmNr) C,"V,(LLt'L Lakl4 SIGNATURE - ^_ <br /> TITLE Ow IN L-9— TAX ID tl <br /> FAIla.vall By Date _ Ac<ouMin#Olflce Praceael Com bfeA Ry Dab <br /> SIIEMITIOATroN AYOIINT PAID DATE Oj PAYMFNr PavYTYPE RECCIPTN# CHEONN ( RECEIVED By wORKPUPE <br /> FEe t 47Vaa 4 //+ ✓�/ <br />