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San Joaquin County Environmental Health Department <br /> DATE 3/2�1%ZU/2 MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> __ __ SITE MITIGATION & LOP <br /> SHADMAREADfOR EHO Y.0-Q ICY OWNER ID# CASE to UNIT IV <br /> OWNER PILE:COriIPLETETHEFOLLOW/NG PROPERTY OWNER INFORMATION.' CHEcxlF OWNER CuaaeHaYoHficE,wITH END <br /> PROPERTY OWNER NAME ( } <br /> First Ml Lest `PHONE/NUMBER <br /> Busmss NAME E-MAIL ADDRESS <br /> me,,co /tea/ Eshle Co,y, an <br /> Owner Horne Address <br /> city STATE zip <br /> Owner Mailing Address )-b Box V o q/ <br /> Mailing Address Ctty f C Stale zip <br /> Phoef/tx AZ g5b38 <br /> CORPORATION® INDIVIDUAL❑ PARTNERSHIP❑ FEDACENCY❑ OTHER❑ <br /> Srrz MmwnoN ENVIRONitilwaAL AaeeasmeNT_VOLUNTARY CLEANUP_WATER QUALITY—MW PIPELINE INVIMIZATION_LOP_ <br /> FACILITY IDM INV# ACCOUNTID Illy 4/R N AssI ED EMPLOYEE LEAn AcENcY:EHD RWQCB_DTSC_EPA__ <br /> 38'a 17(, 7 <br /> FACILITY PILE COMPLETETHEFOLL( INESS/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 EmSTINO Business LOCATION but a NEW TYPE of regulated Bustneas? res ❑ No <br /> BUSIN ESSIFA C1LITYfSITE NAME Q Q <br /> .SrTEADDRESS SUITE# BUSINESS PHONE <br /> 70 S <br /> CITY /� �t/-0/)/-0/) NATE LP g520S <br /> SrOC <br /> ---� <br /> pW,RO OF$UPERYISOR DISTRICT LOCATION CODE KEY'I KEYZ ' <br /> N <br /> Meiling Address/fDIFFERENTfrwn Fec9ltyAddraaa AtteMlon:orCere Of(opbbnel) <br /> i <br /> McUing Addroes Clty STATE zip <br /> SICCoDE APNM COMMENT: --- <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator Identified above. <br /> BuslNEsa NAME ATC Atientlon:orCare Of(opbtana-9 <br /> Ss octal-�s nc, St�C r� ' are_. <br /> Mailing Address PHONE <br /> g18S �. faf�er rove A 111 _ ye0-3SS :q650 <br /> C.tTV STATE zip <br /> �528q <br /> AGL�LAVTApDREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLI,FG A,YD COMPLIANCE ACK.NONIEDGME\'T: ],the undersigned Applicant,certify that lam the Owner,Operolor,or Airrhorketl Agent of this Husinecs,and 1 acknowledge that all PEPvrTREEs, <br /> PewAl TIFS,PJ'i'ORCrstP..W C HARUf s and/or HOVNLT CN.tRGEs assoclated with this operation will be billed to meat the address identified above as the rICCOMWADDAF,TS for this site. I also certify that <br /> all information provided on this application is true and correct;and that all regulated acrivities will be performed in accordance with all applicable SAN JOAQUIN COUPM Ordinance Codes nudlor <br /> Standards and STATE audlor FTOERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and coviroontcnial assessment information to SA,\JOAQM COUN'T'Y ENVIRONMENTAL.HEALTH DEPARTNIEN I'as soon as it is availahte and at the same time it is <br /> provided to me or my representative. //� <br /> APPLICANT NAME(PLEASE PRiHT) JG(/eiY)�!G h/ {(e — ATG 4s54C(O s /12G SIGNATURE — <br /> TITLE Stn/'Or/�fO.��Ql1Q a1'� TAx ID# y99 yo g <br /> Approved By Oats Accountlng(Mice Proceseing Completed By Onto <br /> SITE MITIGATION ANou"w PAID DATeof PAYMENT PAYMFNTTYVE RECEIPT# THECK# RECEIVED BY WORK PLAN PE <br /> FEE: <br />