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San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> 6t I div SITE MITIGATION&LOP <br /> SHADED AREAS fOR EHO MSE QNLYOWNER ID# CASE# SR00.(0 UNIT IV <br /> OWNER FILE:COMPLETE 7HEFOLLOWIAV PROPERTY OWNER INFORMAT/ON: CHscxiF OWNERCvRREmn.roNAxEwrrx EHD <br /> PROPERTY OWNER NAME (Zol) in —?-St <br /> First 1d1 Last PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> Owner Horne Address <br /> city STATE ZIP <br /> kali �, C'+ s3 3o <br /> Owner Mailing Addresa <br /> Mailing Address City State 71p <br /> CORPORATION iNDMDUAL❑ PARTNERSHIP❑ FEo AGENcy❑ OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASEEssmi Nr"YOI.uwrARY CLzANUP_WATER QUALITY_HW PIPELINE INVESTIGATION—LOP <br /> FActuTrlD# INV# AccouNTID #!RO#� ASSIGN®EMPLOYEE LEAoAGENCY:EHD_RYVQCB_DTSC_EPA_ <br /> FACILITY FILE COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE/NFORMAT/ON.' <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 [EJ/ <br /> BusINESS1FActLnY/SITE NAME <br /> SITE ADDRESSSUITE# BUSINESS PHONE <br /> l(O'�"1"t eland 12ouotl, <br /> Cm STATE zip cf3 3 b <br /> BoAn of Supurem R DlsttacT (� ` LocanoN CooEO KEr, KE,2 <br /> Mailing Address 1fD1FFERENTJnom FadlityAdah9ss Attention:orCare Of(opblona/J <br /> Mailing Address City STATE ZIP <br /> SICCODE I V /y( ^ 7Caratfxr <br /> THIRD PARTY BILLING INFO: COmPlete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:or Care Of(optdana/J <br /> /.�QLc S <br /> Mailing Address T;HO"E <br /> So talt�,�I Dnv� S+1L 12-C <br /> CITY STATE LP <br /> 1 sort? `J 5�3 0 <br /> AccouNrMoBEgg for fees and charges OWNER FACILnY/BUSI NESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDCMF.NT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all FERADTFE6t, <br /> FfvALTjEs,ENFORCEfrENTCHA.RGFJ'and/or HOURLY CHARGlS associated with this operation will be billed to meat the address identified above as the ACCOUATADDRFSS for this site. I also certify that <br /> all information provided on this application is true and cormct;,and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations.As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby autborize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENWRONMFJYTAL HEALTH DEPARTMENT'�.r 000 as it is available and at the same 6 it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) SCrl- f 2 �,�i( SIGNATURE <br /> TITLE TAx ID# S7, O 3 7 3 2,2Y <br /> Approved By Date Ac ting Office Procesabsg Comploted By Date <br /> SITEMITIQA ONAMOUNT PAID DATE OFPAVMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BV WORK/(P;LAN WE <br /> FEE:$ <br />