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San Joaquin County Environmental Heal Department <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> / '1 SITE MITIGATION& LOP <br /> • H ra O OWNER IW �t� / _ CASES ��. oo�3 q� UNIT IV <br /> JWNERFILE:COA/PLETErHEFoCLOW/NGPROPERTY OWWNER/NFORMAnoN.- CHEcrteOWNER CupRENrzraxnLEMMEHO <br /> PROPERTY OWNER NAME ( <br /> First MI Last PHOMENUMem <br /> BUSINESSNAME EMAILAODRESS <br /> Owner Heme Address <br /> city —7 STATE ZIP <br /> Owner Meiling Addrwes <br /> Melling Address City ,tState / Zlp <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP 11 FEDAGENCY❑ OTHER❑ <br /> SITE MMQAnoN_ENVIRONMENTAL AOaGaMENT'K VOLUNTARY CLEANUP_WATER OUALnY_HW PIPELINE INVERTHI ATION_LOP <br /> FACIux ID# INV# ACCOUNTIO PR OHIPW AealaNEDEMP Y¢ LEAD AaENcY:EHD_RWQCB_DTSC_EPA_ <br /> CEV> t 154 O D5obSo9 a 8 <br /> PACILITYFILE COMPLETEnIEFOLLOWINGBUSINESS/FACILITY ISITE fwommnoN: <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 /> BUSINEssNeACILIx/SITENAME //�/ • <br /> lr'earc Gc. " "GLGif"iG G-�-� <br /> • SITEAOOREss SURES BUSINESSPHONE <br /> Clx STATE V 1 <br /> BOARDOF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address HD/FFERENTbomFWWtyAddresa AtfenBon:wCare Of(opDmse// O <br /> Mailing Address City � 1� �Srgg ZtP <br /> 91CCODE APN# 7 11 COMMENT: - <br /> THIRD PARTY BILLING INFO'. Complete if Billing Party is diflerreentfrom Property Owner o/rr�}F�acility rOperator idendfled above. <br /> BuSINESSNANE��/ O/( t //�� 'G/�VI�� L//1�✓fU�I K4J/' �"/ /G`^.01 ICPeg19// <br /> Melling Address <br /> CITY STATE/QST <br /> �J �1�✓�6L"Cr'O /A�..� LP <br /> 6CGOLdQ60OSESS forfees and charges OWNER FAciuTYBUSINESS THIRD PARTY BILLING <br /> BIIJJN'G AND CordPLLVICE AnavowLEDe# n S the undersigned AppgtantL certify that I am the OHwer,Operator,or A,dhoAwdAgent of this Swinton,and I adeeowledge that AD PEt FEEY, <br /> Pti¢ =,FN RCEdfFMCa GEs and/or HOMYCe G£s usadand wiW dsi,.pend..wig be biped m drew Wants Rest above As theAtt'ovrvrADDXEcs for ads rite I Also certify Wet <br /> aU m(ormati..provided on this appgcadan M true and corrmq and that all regelaed activ"'a rriU be rformed m ac ce with ag applicable SAN TOAQUm CouNrc Ordfoava Code and/or <br /> Sm dards a.d STATE and/or FF.tteaAl.Laws®d Rtg.iatinw. As the rmdenigned oweer,.peramr,o I t of the property led at�e alwve fatility/tits addreu,l hereby vuth.rhe the release of <br /> any and AU..fta and eovir..mental.,.matt i foresatie.m SAN TOAQUIN COUNTY BNVIRO NTAL NRALIH EPARTMT.NT As soon es it is available And at the same time it is <br /> provided to..or my repmmmtive. <br /> APPLICANT NAME(PLEASE PRINT) .1� 12'1 f' 9wru R <br /> TYLE Idi� / c� ea� S� TAxIDB 0-0��'��P <br /> .vads Dab A...offn OIP.e Procaul Com lebtl 8 Da <br /> MITIGATION AMOUNTPAID DATE OF PAYMENT PAYMENTTYPE RECEIPTS CHECK# RECEIVED BY WORKPLANPE <br /> 7F7EE; <br />