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San Ouin County Environmental HealthePartment <br /> DATE 4� -2 ' MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> J SITE MITIGATION& LOP <br /> SHADED AREAS FOR END USE ONLY OWNERIDB CASE iM UNIT IV <br /> �WNER FlLE ICOUPIEVE7NEFOLLOWNG PROPERTY OWNER lwoRlwanonr CNECKfir OWNER coaRENnYONRLEWM EHD <br /> PROPERTY OWNER NAME <br /> First Ml Last PHONENUMaER <br /> BUSINesSNgME EAIML ADDRESS <br /> Owner Home Address <br /> City STATE 21P <br /> Owner Mailing Address �S �t2 s`/ / / �'�•dG/`Q. ��s' /�QOJ"' <br /> Mailing Address City State Zip <br /> CORPORATION IN IF <br /> PARTNERSHIP 13 FED AGENCY OTHER❑ <br /> SITE MTOATION_ENVIRONMENTAL Aninwag Nr VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FAciurYIDM INVN ACCOUNT ID PRWRO ASlnopeD EM vee LEAD Aoeacv:EHD RWOCB DTeC_EPA_ <br /> (o 509 0&$ <br /> FACILITYFILE CawmEm7wFoLLowiNGBUSINESS IFACILITY/SITE/NFORMATIoAc <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO <br /> IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO <br /> BUSINESSIFACIurriSITENAME �Y <br /> SITE ADDRESS SUITE# BUSINESS PHONJE <br /> h�SVPERVIC— <br /> /f/_ ,4STATSfM DISTRICT LOOATION CODE KEY'I KEY2NO/FFERENThwnFic/////QAddreae 1Attention:orCare Ol toptlare/JZ 'GLCr Y ! . T �7City ` -STADE ZIpf APNOCP4M& CoMNENT: �' <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator idenblfledabove. <br /> BUSINSNAME.,I'�c ��/1G e/sari - � �,WiOf(OPUMW) <br /> Melling Address 4 <br /> �j <br /> /�V4�.ST �J'CI�� �✓� U/Tim. �7P /� ���g�/ �` �JyI�D <br /> CITY � V�STATE LP <br /> AccouttrAaaNEw for fees and charges OWNER FACiuTYBUSINESS THIRD PARTY BILLING <br /> BrmviG AND CowLuoIcE Act ov t DGMENi: 1,the uaderrigned Applicant,certify that ism the Omer,Operner,or AaTFarfudAgent of this Budom,And I acknowledge drat vD PERMIT FPEs, <br /> PEN.a.ars,ENFoar:M CI GEs And/or HoIwYCNARGEs associated with this operation will be billed m n rat9ter4rm identified above As theAmofn%TADDREee for this site. I also cerofy that <br /> all informatiao provided on this ap,Ur.6.a true vo l corrar And that all regulated activities will he performed in acconlance with AU applicable SAN dOAQtmc COUNTY Ordinance Cada And/or <br /> Staodards And STATE And/or FEDERAL Laws And Regulationx As the Undersigned owner,operator,or sgdet of the property bpated at the above fact ityhio,address,I hereby authorae the release of <br /> say and all results And mYvoomeoml...t ioformadoo to SAN TOAQUIN COUNTY ENVIRONWNTAL HEALT"EPARTMENT As..on As it is available And at the same time it is <br /> provided to me or my representative. \ - <br /> APPLICANT NAME(PLEASE PRINT) <br /> TLE �'::�) 1 �O� .5�. TAX 11)0b_O�.aJ � j <br /> Approved By Data Aoeauntl Olfioa Prowasl Com b4tlB V Dab <br /> SITEMITIGAT�ON AMOUNTPAID DATE OFPAYMENTPAYMENTTYI RECEIPTS CHEECN0 (�� RECEIVED BY WORK PLAN PE <br /> FEE:11J 1 �. 440 <br /> At 44 ;011 <br />