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San Joaquin County Environmental Health Department DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM r�.� -- — _ _ SITE MITIGATION & LOP SHADEDM FOR HD seO OWNER ID# CASE/ UNIT IV OWNER FILE:COMRXMTHEFOLLOW)NG PROPERTY OWNER/NFORMA770N.' 11=1YFOWNER 0LAMi6VTLroH FHEwrrH EHD � 7BUSINE� tFirst Ml Last PHONE NUMBER AME /J . E-AAAILADOS e Address N. Q +DtiA4- city STATE zP c15 o ; CA 9 tLl L 2 Owner Mailing Address e 0. 130 zt, 9S Mailing Address City av I CJ>R ZIP cjSzy CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ FED AceNCY❑ OTHER❑ SITE MITIGATION ]_�\ENVIRONMENTAL ASSESSMENT—VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP FACILITY ID It INV# AccouNTID PR#/RO# ASSIGNED EMPLOYEE LEADAGENCY:EHD V RWQCB_DTBC_EPA_ _l FACILITYFILE COMPLETE 7HEFOLLowNG BUSINESS/FACILITY/SITE/INFORMATION.' Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No BUSINESS/FACILnY/SITENAME TA A£Z A 2� SITEADOREs, I�� C SUITE# BUSINESS PHONE N Loy -?6 fl)o9 CITY STATE IJP Loo ; 5szVz BOARD OF SUPERVISOR DISTRICT LA nOli CODE KEPI KEY2 Mailing Address IfD/FFEREN7/rom Fec//RyAdbrass Attention:orCare Of(optona/) Mailing Address City STATE zip —11 SIC CODE APN# COMMENT: i 1i THIRD PARTY BILLING INFO: Complete ff Billing Party is different from Property Owner or Facility Operator ident(f/ed above. BUSINESS NAME Attention:orCare,Of ibimbi tW) Meiling Address PHONE CITY STATE LP 6cCa/MAOORGss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Ofweatar,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, P£NALITE%ENFORCEMENT CHARGES Sadler ROURL Y CHARGES associated with this operation will be billed to me at the address identified above as the Aoyo(/NIADDRFSS for this site. I abs certify that W information provided on this application M true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards Sad STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facilityhite,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 N is available and at the same time ith; provided to me or my representative. 11 1 e APPLICANT NAME(PLEASE PRINT) TM o?N V ��J E)),4 &GNATURE � _ TITLE UOn.�r MAPiAfrt/ TAX ID0 Approved By Data Aeeeunting Office Proneaalna Completed By Date SITE MITIGATION AMOUNTPAIO DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK RECEIVED BY WORK PLAN PE FEE: