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2016 SAN JUIN COUNTY ENVIRONMENTAL HEALTH DORTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE T -21y � I SHADED AREAS FOR END USE <br /> OWNER FILE.-COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CNEcKAPUwNPRisOuRREN7LraNRLE*7m E H D <br /> PROPERTY C- � C), ; PHONE <br /> OWNER NAME 1RST l-XX ST ll <br /> BUSINESS NAME E-MAIL ADDR <br /> v5 M ad;. <br /> OWNER HOME ADDRESS ATTENTION:OPCARE OF(OPTIONAL) <br /> CITY <br /> OWNER MAILING ADDRESS <br /> MAILING ADDRESS CRY y STATE z'IP <br /> ❑CORPORATION ❑INDNIDUAL ❑PARMERSH P ❑GOVERNMENT ENCY / ❑RESPONSMLE PARTY [OTHER 1-1-' <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY LEAD— QCB LEAD— <br /> ASSESSMENT CLEANUP C4tQCB <br /> 'VE ACTION QUALITY(WDRI ❑ DTSC LEAD ❑FED EPA LEAD <br /> 2950 2953 29601352613527 2965 2959 2954 <br /> FACILITY FILE:COMPLETE BUSINESS I SITEI PROJECT INFORMATION: <br /> IS THIS A NEN!PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES NO ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ NO Lg <br /> BUSINEesfFACILRYtSnE1PROJECT NAME �---� APN: <br /> Lr �"1 �c't C,� 2-6:3) <br /> SITE ADDRESS I PROJECT LOCATION - 1' BUSINESS PHONE <br /> eL <br /> CRY STA71P 2 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS <br /> MAILING ADDRESS CRY STATE zip <br /> SIC CODE COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ' I {, ATTENTION:ORCAREOF (OPTIONAL) <br /> MAILING ADDRESS <br /> � �y-?. �U"3 �.1�rj� � `� PHONE <br /> CITY T l i ZT, <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACIUTYIBUSINESS❑ THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1, the undersigned Applicant,certify that I am the Owner, Operator,Authorized Agent, <br /> or Responsible Party and 1 acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated <br /> with this project will be billed to me at the address identified above as the ACCOUNTADDRESS for this site. I also certify that all information <br /> provided on this application is true and correct; and that all regulated activities will he performed in accordance with all applicable SAN <br /> JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned <br /> Owner, Operator,Authorizer)Agent, or Responsible Party for the project located above under facility/site address, I hereby authorize the <br /> release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL. <br /> HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) y b�Gt 4,� SIGNATURE <br /> TITLE TAX IO# <br /> FA#: OWNER ID#: ACCOUNT#: ASSMNED TO: <br /> PL-0.2� .233 9-z- ���� 1 b A,eoo43273 <br /> PRM ACCOUNTING COMPLETED BY.a DATE: <br /> 1� <br /> 9-3-2015 <br /> Site Mitigation MFR 29- <br />