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STATE zu' 9 sly( <br />THIRD PARTY BILLING <br /> VCralatanr,,,.. <br />FacturY/BuswEss F ACCOURL41212RESS for fees and charges OWNER <br />Mailing Address <br />CITY <br />33d/ #2,00,<1 copy <br />4 cel?1,41 4141 CA <br />BUSINESS Nowa 6- / <br />Attention: orCare Of (0)01'10,189 /04,/ 4/„;;,./ker tv 6-,v7 rt'ir one% <br />PHONE <br />DATE <br />DAVE° AREAS FOR EI-SO USE ONLY <br />664//1/ <br />San Joaquin County Environmental Health Department <br />MASTER FILE RECORD INFORMATION "MFR" <br />OWNER 1111 <br /> <br />1 CASE X <br />GREEN FORM <br />SITE MITIGATION & LOP <br />UNIT IV <br />OWNER FILE :COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION: CHEM IF OWNER CURRENTLY ON FILE WITH END <br />PROPERTY OWNER Woe <br />— <br />(.144) 1'37 —g /( <br />Fesi MI Last PHONE NUMBER <br />BUSINESS NAME <br />C.X . 4.--r .c <br />E-filAIL ADDRESS <br />_ <br />Owner Homo Address <br />City STATE ZIP <br />Owner Mailing Address 3 4,, r I,/ zr/ 4,4...4 <br />:.) <br />,.... „ <br />, 7_ <br />Mailing Address City Motet <br />4 <br />Zip5"-Ierc,Avp., <br />1 1 C*2€12 <br />CORPORATION 0 INDIVIDUAL 0 PARTNERSMP 1-7 FED AceNGY 0 <br />SITE MITIGATION ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP WATER QUAUTY NW PIPEUNE INVESTIGATION LOP <br />FACILITY ID # lnvU EpA PRff/R03 ASSIGNEE) EMPLOYEE <br />ant <br /> LEAD AGENCY: ENE; RWOCR 1/77TSC <br />.nnasaasnamas........--sneen <br />FACILITY FILE COMPLLIL THE FOLLOWING BUSINESS / FACILITY / SITE INFORMATioN: <br />Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES 0 No Pi <br />Is this an EXISTING Business LoCKnON but a NEW TYPE of regulated Business? YES 0 No „IFf <br />BUSINESS/FACILITY/SITE NAME <br />SITE ADDRESS . / ,. SUITEN . EILISINESSpi ‘OPIE , ryorek4t, ik o - /4 4 , ye, --c't ‘'' ciktrrs4 71 Pie I- r0-1-71 ef' J CITY <br />5;4 <br />STATE ZIP <br /> <br />BOARD OF SUPERVISOR DISTMCT LoernouCooE Keel , KEy2 <br />II <br />Mailing Address if DIFFERENT from Facility Address Attention: orCare Of (optional) <br />Mailing Address City STATE ZIP <br />SIC CODE APNS <br />1. <br />Comma: , <br />chi 1-1tfe a I/. 4,,,„ „(.....,71,)6,0 / 3 73 CO 5-7 <br />THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br />BILLING .s.ND COMPLIANCE ACKNOWLEDGMENT: I the undersigned Applicant, certify Mat I am the Owner, Operalor, or Aulltorited Agent of this nosiness, and I acknowledge that all PERMIT FEES, <br />PEVALTIES, ENFORCEMENT CI,WRGES and/or /faun Y CHARGES eslaciated isith this operation stilt tw baled lame at the midi ess identified abOve as the ACCOUVT/10011.45S for this site. I also certify that all <br />interns:dim provided on this application is trite and correct: anti that all regulated activities will be performed in accordance with all applicable SAN JOAQION COUNTY Ordinance Cedes and/or <br />Standards and STATE antlior FEDERAL Lasts and ReguLltions. As the undersigned owner, operator, or agent of the property located at the above facilit)isite address. I hereby authorize the release of <br />any and ail results anti filliTORTEIERLA assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DErARTNIENT aa soon as it is available and at the same rinse it is <br />provided to toe or my representative. <br />APPLICANT NAME (PLEASE PRINT) SIGNATURE /ef,i'VZ <br />TITLE 4fleCr .41`e, <br />TAxID# <br />ii3747Y11 <br /> <br />Approsnd By onto cm[noo Processing Completed By 1 Date - —es.= <br />SITE MITIGATION <br />FEE: $ <br />AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE 1 RECEIPT X CHECK X <br />- <br />RECEIVED Hy <br />._-. <br />WORK PLAN PS