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12/03/2015 11:59 510886__x0 FJ LEONARDO & SON RECV'F.D <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT DEC Q 7 2015 <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM ENVIRONMENTAL HEALTH <br /> DATE �^ SMADED(f�IIO�i <br /> OWNER FILE:COMPLETE PROPERTY OWNERI RESPONSIBLE PARTY INFORMATION: OA vicW0 Nrsl W0"Wrryww OEM <br /> PRO►Elm' T 3 , e..0 n et /- � �150n. .1. a <br /> Oy. NI <br /> /J / <br /> COW*in NATE AFT LA9f D D t�rG <br /> BUSSIFSs NAMEDOOR" <br /> _ _ �-� Y'1 Q r 1r`' ��2CI,.2 rr�r� ��i•►,n�o_.f.�_ f <br /> OWNER NOPE AOOReSs ATT'ENTON:OIP CAI40P(� L} <br /> cay / ('—"",4 2 ,J a $TATE ZIP <br /> IWNiR MAILING ADDRESS --1•^ / - M .- —. -- --` <br /> I. MAEJNO ADDRE"CrtY---- STAT!--- --- Zo --' <br /> ❑CORPORATION ❑INONIOVAL ❑PARYNERONIP ❑GOVERNMENT AGENCY ❑RSOPot sou PARTY ❑OTNER <br /> 91 ENVIRONMENTAL ❑ END LOCAL VUNTARY ❑ RWOC8 LEAD- ❑ RWOCB Lean- <br /> OL ❑ DTBC LEAD ❑FED EPA LlAD i <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2954 <br /> 2950 -- 2953 I_ 29601352613527 _-- 2965 <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION; <br /> to THIS A Hew PROJECT LOCATION%T PREVIOUSLY REGULATED aY TME ENVIRONMENTAL HEALTH DEPARTMENT? yes ND ❑ <br /> Ie T", AN EXISTING PROJECT LOCATKM,SVT A NEW$COPE OF WORK? YEA ❑ No 13 � <br /> BUs1NESaIPACKRYr61TE1PROJEOT NAPE �i-� Lfa- (,L,t,�O(rpt?C 7- 2 P-e. <br /> $ITT ADORE"I PRDJEC7 LOOATIDN !jC 4,'�i/ C!S/ •S 7A'. ou Ne"PNONR <br /> STA <br /> j.. <br /> SpARD OFSUPERVMOR DISTRICT LODATION CODE Kett KEY2 <br /> MALLIN(J ADORESO,IF DIFFERENT PROM FAOA•RTT ADDRESS <br /> OADOREOS CI*Y __ STATE Zv <br /> TNIRO PARTY BILLING INFO:COMPLETE IF BILLINIO PARTY IS DIFFERENT FROMPROFERTY OWNER OR RESPON5IDLE PARTY IDENTIFIED ABOVE, <br /> t3u� swese NAMe Arre-qINTION:ONCME 00 (OIR/R AW) _�A <br /> �MAP-NG ADotteEe / � ;� ✓1 � "/ �7"' J�'� / �/ PINE ,fYf-a 5 3eF-' ' <br /> .Y/a <- <br /> Za ?1 YS;../� <br /> ACOOUNT ADDRESS TO OEND Pies AND CNAROES' OWNERO FACIUTY18V5INESS0 TNSto PARTY/BILLINOO <br /> IJI1,i,INc.%Nu COM1113,0CL Act:acwv'LF.DCMI NT: 1,the undersigned Applicant,certify that I am the Owner.Operator, 4ulhorrzed Agen(. <br /> or Responsible Purm and 1 acknowledge that all Pi..mirm Fens,I'E.f ibTJliS',FNFURCEMEwT('114RGE.S and/or H0(-R1,),'CN4R(;J_V associated <br /> with this prujeet will be Wiled to me at the address Identified above ns the AC'COU,vrADDRESS for thin site.I also certlf� that all infunnntlun <br /> provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN <br /> JOAtivt1 ("Qt NTN 0I41)INANCY. ('OUFS And/or STA.NDARIB and STATE and/or FF.I)FRAI, Laws and REGULATIONS. As the undersigned <br /> Owner, Uperaeor•, Aurhori;ed.Jl;errt or•Xe.iponsible Purn,for the project located above: under facility/site address, I hereby authorize the <br /> release of any and all results. reports, and other en%-irownintal assessment information to SAN J0AQt.!fN Cl1l N71' FNS']RL1NMk:N1'11. <br /> HEALA H DUARTMENI 8$W011 as itis available and at the same time Ills provided tome or my representative. <br /> ,z..- i+k <br /> APPLICANT NAME(PLLAIE PRINT) � 1,.� 4y~ �:� <'.1f $WNATVRE <br /> TITLE c't tan/ xr a N...�G,.� i TAX ION <br /> PA N: rA007 3 2-3 <br /> 3 <br /> OAT!: <br /> OWNER 10 S: z/? ACCOUNT r; - ARSNINED Tor <br /> PR S: AOOOUNTINO OOM►LiTSD BY: �• IU I <br /> 9.3-2015 <br /> 5ao Mttigatlon MFR 29- <br />