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r <br /> San Juin County Environmental Health Dbpirtment k ,r <br /> DATA MASTER FILE RECORD INFORMATION"MFRS' GREEN FORM <br /> dAA (y SITE MITIGATION&LOP <br /> SH*DED FOR FHP us ON r OWNER I D# CASE# 5ti O b 44 3 7 X UNIT IV <br /> OWIiER FILE:COMPLETETHEFOLLOWWNG PROPERTY OWNER/NFORMATWON.'` CnecxtF OWNER Cm REwnrcwFjxEw m EHD <br /> PFAWO rY OwNER NAME 'HgL U-7- A <br /> First MI last PHONE NuatsER <br /> EkJW&Ess NAME E-101411ADORESS <br /> r- n! <br /> Owner home Address <br /> Wi9194Dcity QO/4 /y <br /> GLcAT V STATE <br /> LP <br /> S <br /> Owner AAtdlirtg Address V <br /> W00D A D T-20 17 <br /> MaftV Adds Cft sty Z <br /> I <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER KL <br /> SITE MITIsmm ENVIRONMENTAL ASSESSMENT_VOLuNTAWV CLEANUP_WATER QUALITY_NW PIPELINE INVESTIGATION_LOP_ <br /> FACRITY ID INV# ACCOUNT Ib PR Os AssIGNED EMPLOYEE LEAD AGENCY:EHD_R111fQCB_DTSC_EPA <br /> !�4 <br /> FACILITYFILE CompLETETHEFOLLOwNGBUSINESS/FACILITY ISITE INFORMATION' <br /> Is this a NEW Business LOCATION not previously regulated by the ENwRamaENTAL HEALTH DEPARTMENT? YES ❑ NO <br /> Is this an E)QST NG Business LOCATION but a NEW TYPE c f regulated Business? YES ❑ No <br /> BUSINESSFACU Y)SRE NAM <br /> LZ- S <br /> SFTFADOREss SUITE BUSINESSPHONE <br /> l yo l-e A M A NT <br /> CITY STATE <br /> TIP <br /> M A C A C �! S3 3 <br /> BOARD OF SUPERVOM Ots "cT LOCATION COOS KEYt KEY2 <br /> Mtsil V Address ffDAKFF77ENTlrarrr Fac/fityAr>&ws Attention:orCare Of(optbetell <br /> Maling Address City STATE LP <br /> SICCODE APN# COMMENT: <br /> THum PARTY BILLING INFO: Complete if Billing Party is different fromProperty Owner orFacility Operator identified above. <br /> Busmss NAME Mention:arCare Of(opHarm# <br /> MairNrs Alftireaa PHONE <br /> 797-q&3 -Z361:1 <br /> carr STATIE ZIP <br /> � C—A q S 417,E��1tl1�M A <br /> Al_AOIt77fTM for fees and charges OWNER FAciuTYIBUSINESS THIRD PARTY BILLING <br /> BII.LVJG AND COMPLIANCE ACKNOWLEDGMENT: L the undersigned Applicant,certify that 1 am the thmer,0 peralar,or Authorized Agent of this Business,and 1 acknowledge that all PERMIT FEB4, <br /> PENALTIES,EATORCDIFN7CHAJ?GE:and/or HOURLYCHARGL'associated with this operation will be billed tome at the address identified above as the ACCOUNTADDgm for this site. 1 also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COIMv 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 authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the some time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) /S FL r� �' �I �I SIGNATURE <br /> TTIT_E G r� (�f� TAx ID# �. <br /> S 7 A F t= tr �OLOG-(ST 9s5---�?7(., <br /> aY Date Aeeounting Office Processing Completed By Date l i <br /> SrrE PA--T,— AmoUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# TECEIVED BY WORK PLAN PE <br /> FEE: <br />