Laserfiche WebLink
San .,`I!bquin County Environmental Health apartment <br /> DATE 11 3-05-2015 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED meas FOR END OBE ONLY OMER 10# CASE#S�C�7/�/ �7 UNIT IV <br /> OWNER FILE:ComPLETEPROPERTYOWNER/RESPONSIBLE PARTY INFoRfAitnonf: (CNEDUE•S'DWNERCmtRENRreaFAENamsEHID <br /> PROPERTY OwNFA NAME FAIRWAY ESTATES LLC ( 921 6814393 <br /> First MI Last PHONE NUMBER <br /> BUSINESS NAME Ei ft.ADDRESS <br /> Fairway Estates <br /> Owner Home Address <br /> 2151 Salvio Street Suite 325 <br /> City STATE LP <br /> Concord CA 94520 <br /> Owner Melling Address <br /> Same as Above <br /> Mailing Address City State zip <br /> fJ CORPORATION ❑INDIVIDUALy❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT—VOLUNTARY CLEANUP WATER QUALITY HW PIPELINE INVESTIGATION LOP <br /> FACILITY ID# INV# ACCOUNT ID PR#/RO# ASSIGNED EMPLOY EE LEAD AGENCY:EHD X RWQCB_DTSC EPA_ <br /> JvHrv'� <br /> FACILITY FILE: COMPLETE BUSINESS/SITE/PROJECT fNFORMAT(oN: N� <br /> Is this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES L'J No ❑ <br /> Is this an ExISTING Project LOCATION but a NEW SCOPE OF WORK? YES ❑ NO [5 <br /> BusimeaBIFAclUTNISRE/PROJECT NAME Fairway Estates <br /> SITE ADDRESS/PROJECT LOCATION SURE# BUSINESS PHONE <br /> 1155 West Center Street (925)6814393 <br /> Cm STATE LP <br /> Manteca CA 95337 <br /> BOARD OF SUPERVISOR DISTRICT � LOCATIONCOOE V AY KEY1 KEY2 <br /> Melling Address KO/FFERENTfrom Fed//tyAddress Attention:croons Of(optlona/J <br /> 2151 Salvio Street Mr.Scott Fujihara <br /> Mailing Address City STATE LP <br /> Concord CA94520 <br /> SICCOOS APN# )-/ <br /> /^7_ O_ - ^O5COMMENT: <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner or Responsible Party identified above. <br /> BUSINESS NAME Advanced GeoEnvironmental, Inc. Attention:or Care Of foptlanal/ <br /> Mailing Address PHONE <br /> 837 Shaw Road 800 511-9300 <br /> Qm STATE LP <br /> Stockton CA 95215 <br /> AccauenrAOine®S for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,Certify Dot I am the(Artier,o(Wator AYMOrized Agent,Or Ropossible Pnrn'and I acknOWledge that 811 PERMITFEES, <br /> PENAL EMS,ENFORCEMENT CHARGES and/or HOURLY CHARGES asocciated Kith MIS pmJPCt will be blued tome at the adrlr S identified above AS the Act oUNTADDRES'S for this Site. l also Certify that all <br /> information provided on this application is Due and correct,and that all regulated activities will be performed in accordance with all applicable SAN JOAQUm COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned Owner,Operator,Auamrind Agent or Responsible Party for the project located above Under facility/site address,I <br /> hereby authorize the release of any and all results,reports,and other environmental assei9malt information to SAN JOAQUINCOUNITY ENVIRONMENTAL HEALTH DEPARTMENTas soon As it <br /> is available and at the same time it is provided to me or my representative. ,Q <br /> APPLICANT NAME(PLEASE PRINT) Robert Marty SIGNATURE <br /> TITLE President-AGE <br /> TAx ID# <br /> roYW Data A::,Ming OMDa Proacconng Complains By Dale <br /> BRE MRIGATIGN AMODNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PuN PE <br /> FEE:S�Jc^ 2 3 !-1� eC C / / �4 ( eawA�fGe :2950 <br />