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San Joaquin County Environmental Health Department <br /> DATE <br /> E:J MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION 81 LOP <br /> SHADED AREAS FOR EHD UAE ONLY OWNER IDS CASE#5,R4w /� rjQ// UNIT IV <br /> OWNER FILE.,COMPLETE THE FOLLOWING PROPERTY OWNER INFORMA TION:-C1(p /(JC`HECX lF OWNER CURREHTLYOHFJLEWrTH EHD <br /> PROPERTY OWNER NAME -'r" Dltf S ( ) <br /> First M! Last PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> Owner Home Address �j <br /> V (A <br /> City STATE LP <br /> g� <br /> Owner Mailing Address <br /> Mailing Address City state Zip <br /> CORPORATION❑ INDIVIDUAL 0 PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MI ewrioN^ENVIRON EMTAL ASSESSMENT—VOLUNTARY CLEANUP_WATER QUALITY HW PIPELINE INVEMIMATION_LOP <br /> FACILITY ID# INV* AcccuNT ID I PR RO <br /> kss�yU <br /> FACILITYFILE COMPLETETHEFOLLOWING BUSINESS I FACILITY I SITE INFORMATION: <br /> Is this a NEw Business LOCA-noN 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 /> BUSINESWFACILITYISRE NAME <br /> SITE ADDRESS 7- .SURE iy BUSINESS PHONE <br /> Cr" STATE 21P <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address ffD1FFERENTf1rom FacllltyAddrees Attention:orCare Of(opUawl) <br /> Mailing Address City STATE ZIP <br /> SFC CODE APN! COUMENT: -5-Rao C4 <br /> 7.19-OZ-p z CroET W Ir-i-t 5Ple,t:W37t9 .5-04ZU5 TO tt5GJ>'EVJ d�s <br /> THIRD PARTY WILLING INFO. Complete if Billing Party is different from Property Owner orFacility Operator Identified above. <br /> BUSINESS NAME Attention:or Care Of (opdortalf <br /> C' ti — T /� <br /> Mailing Address C�� , PHONE <br /> CITY STATE LP <br /> CA 4Z Zl- <br /> AaQ2Ld 84 for fees and charges OWNER FACR.iTY/BUSINESS THIRD PARTY BILLING <br /> BILLING AHD COM?UANCE AC"OWL6OGMrlrfr: 1,the undersigned Applicant,certify that I am the Owner,Operute,or Authorial Agent of this Business,and I acknowledge that all PEx.NrT FEES, <br /> PENALttFs,ENFoxcFArEN7 CHAxces and/or NouxLYCHARcEs associated with this operation will be billed to me at the address identified above as the ACCOUNT ADDRESS for this site. I also certify that all <br /> information provided on this application Is true and correct;and that all regulated activities will be performed In accordance with all applicable SAN JOAQUIN COUNFY Ordinance Codes and/or <br /> Standards and STATE and/or F1EnrRAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,1 hereby auftrin 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 of the same time it is <br /> provided to me or my representative. - <br /> APPLICANT NAME(PLEAsE PRINT) <br /> TITLE s , •Tax ID# �^�J <br /> d By Date Accounting Office fsreeeaai Completed By oats j i� <br /> ' rL� <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT* CHECK N RECEIVED BY :WORt4 PLI 'I, I� <br /> FEE: <br />