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SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE /O _g_(3 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> ______._...._...._...._._..________._._.. SITE MITIGATION &LOP <br /> SHAPEDOWNER 10# �(O y / (�'A$� S(zcx)4 8 2 x 3 UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECKIFOmERisCURRENTLYONFKEwtm EHD <br /> PROPERTY OWNER NAME i r\ �: l `'k o S (arc 4$(O- 4 t 4$ <br /> FIRST ASI LAST PHONE NUMBER <br /> BUSINESS NAMEE-MAIL ADDRESS <br /> Avst�r� Roc1� �vsir�esS F�c�r+Y��r'S �;11F� \iosL. aln°° `Corn <br /> OWNER HOME ADDRESS <br /> LA (o 3 mom ct{ g1va. sup �e 5" <br /> CITY STATE C A LP 3 3 <br /> OWNER MARJNG ADDRESS <br /> MAILING ADDRESS CITY STATE ZJP <br /> ❑CORPORATION ❑INDIVIDUAL ®PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT)( VOLUNTARY CLEANUP—WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INV# AGCDUNT ID_ PR Rp# ASS16NE0 EMPLOYEE LEAD AOENcr:EMD_ RWQCB_DTSC EPA_ <br /> 2t9 Ll 7S 05- Flo <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: n� <br /> ISTHIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES I.rNO ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YEs ❑ NO W <br /> BUSINESS/FACIUTYISITE/PROJECTNAME S{1 ,� RQ Row `rn +s <br /> SITE ADDRESS 1 PROJECT LOCATION �ID 1� \ 1� OLtl c't SUITE# BUSINESS PHONE <br /> is e c tin 6F- �Ust k n R � (v^ p-Ci -CcA rn <br /> CITY .STATE Zip ct S 3 3 <br /> m arN ke co, CA <br /> BOARD OF SUPERVISOR DISTRICT CLOCATION CODE Cj y KtY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> z . 2ig-a <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME i ��vo V�-^ C t1 S L.l`-�.I,(1 ATTENTION:OR CARE OF(OPTIONAL) <br /> Lc�s�rzt Loo or baVQ BuC..k <br /> MAIUNGADDRESS PHONE '11(.0 -'-J3-75- !970 <br /> '2-4ctl b o aA mars Av 5 30-21 ' <br /> cTTY zip <br /> we-.-* S acrarr e...n+o $TATE <br /> C 9'S q <br /> ACCOUNTAODRESS TO SEND FEES ANO CHARGES: OWNER❑ FACILITYIBUSINESS❑ THIRD PARTY BILLING® <br /> BILLING AND COAIPI.IANCE ACxNOn LEnGAIE.NT: 1,tie undersigned Applicant,certih that I am the Owner,Operator,AnlhorfcedAgeln,or Responsible Parry•and I aclarovviedge that all PERVrTFEES, <br /> PEI,ALTI£S,LNTORCE.If£,\TCHARG£S and/or HOL'RLI'CHARGES associated with this project mill be billed to we at the address identified above as die ACCOU.,VT ADDRESS for this site. 1 also certify that all <br /> information provided m this application is true and correct;and that all regulated activities Bill be performed in accordance pith all applicable SA.'i JOAQLTN Coumy ORDIIrA\cE CODES and/or <br /> STANDARDS and ST.TTE and/or FEDERAL Laws and REmATIONS. As the undersigned Omer,Operator,AHlltortedAgeu4 orRcsponslble Party for the project located above under facility/site address,I <br /> hereby aushorLm the release of any and all results,reports,and other environmental assessment information to SAI'JDAQtiuY Cotrvry F.NvutoNaw-N-rAL HEALTH DEPAxTmErT as soon as it is available <br /> and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) Lc�-u r a. L o n C SIGNATURE (:-:2SCLe4n[A <br /> TITLE f'a r�tone nt'�it E x15'1 n e'r" TAX ID# 68- O y 1 `I (o(Q 2 - <br /> APPROVED BY DATE ACCOUNTNG OFFICE PROCESMG COMPLETED BY DATE t <br /> $ITE MITIGATION NT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE ku <br /> FEE;; 3757 �� !�- <br />