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San Joaquin County Environmental Health Department <br /> €?ATE MASTER FILE RECORD INFORMATION"'MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> 914AWD AFAa FOR EHDIIaEONLY OWNER IDN ✓ASSN UNIT IV <br /> OWMER FILE.COMPLETE T�NTEFOLLOWING PROPERTY OWNER INFORNATIORt.` CnEcx/F OWNER CURRENrLYomnirtym EHO --j <br /> j� <br /> PROPERTYOwNERNMIE / 1 n <br /> �//C✓ First Mt Lost PHONE NumoER <br /> BUSINESSNAME 0 I E-MAILADoms <br /> rr— <br /> Owner Home Address2 21 <br /> PIN <br /> city J l E ZtP t J <br /> OwnerMallin Address <br /> Mailing Address City Stets Zip <br /> CORPORATION I_i INottaDUAt(] PARTNPRSHIP❑ FHD AGENCY❑ OTHER <br /> I ZrrE MITIGATION_ENmIRONMIENTAL AssusamNy VaLuNTARY CLEA&MP_ ATRR QUALITY HW PIPLUNIS INVES11*9177ION_LOP_ <br /> FAc1u7Y1DN IML# AccOUN71D PR#IRO# AssulmEmpLoYEe I LEAD AGENow.EHD_RWQCBeDTSC_EPA_ <br /> FACILITY FILE COMPLETETt/E•FOLLOWRVGBUSINESS/FAQrlll6Y/SITE INFORMATIOhf., <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES M No <br /> Is this an ExhsTiNG Business LOCATION beta NEW TYPE Of regulated Business? YES❑ No <br /> BUSINESSIFACILRY/Sac NAME y/ �Y?J (�y��(+�^ <br /> SITE ADDRESS l�/. -}/ CMCJ✓ O (�!O` /�Y-' `/L/j./`C�����W` i d..c/e '" '4✓Un 6'N C P J!A <br /> Cay / �f J STATE <br /> BOARD OF SuPERNIsORDISTRi T LOGATtON CODE IfEY4 KEY2 <br /> Mailing Address fIDIFFEREMTff neAbol/flyAddre= lien• cam Or(opmans/) <br /> �g -p"' STATE ZIP <br /> MaNing Address City „z 4� <br /> SIC CODE APN# �j Cb <br /> THIRD PARTY BILLING INFO- Complete if Billing Party is different from Property Owner orFacitity Operator identibed above. <br /> BUSINEss NAME�n J >�s' • i !-f'i <br /> LA <br /> 1� <br /> Attention;orCare Of(apt3analJ I i I p�G. <br /> W \_ Uj 'I (� I J L3J t <br /> Mailing Address 0 <br /> Cm � �^ STATE ZtP <br /> t <br /> @CDQt!/a2A09-N forfeaes and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> HILLINC AND COMPUANCE ACKNOWLEDGMENT: 1.the undersigned Applicant,certify,that I am the orvner,Operaror,or Authorized Agent of this Business,and I acknowledge that all Pmnur FEES, <br /> P>5a ttneS,F.vFoacT.trcvrCxnnces and/or Hotrszr CHARGES associated with this operation will be billed to me at the address Identified above as the Arrno vrADDaeSs for this site.I also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in nceordance with ail applicable SAN JOAor.w COU'.'GY Ordinance Codes and/or <br /> Standards and STATE and/or FEDEP LL.Laws and Regulations As the undersigned owner,operator,or agent ofthe property located at the above facility/site address,I hereby authorize the retcase of <br /> any and all results and emironmemal ssmcnt'nfonnation to SAN JO QUIN COUNTY NYTRONAIENTAL FIEALTII DEPARTAIENT as soon as it is available and at the same time it is <br /> provided to me or my represenariva I F!�! J <br /> APPLICANT NAME(PLEASE PRINT) f} f��(/J� l ��/J�(lc- <br /> TITLE t� v t_CJ'f G� ( `-' TAX - <br /> provedg DOW / Accounting ORln®Pro-salng Completed BYQate <br /> SITE M-GATION AraOUHT PAID DATE OP PAYmENr I--NTTYPE RECEIPT# CHEGK# ftEOGRIED BY WORK PLAN PE <br /> FEE: <br />