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SANQUIN COUNTY ENVIRONMENTAL HEAL�EPARTM <br /> SITE MIT�ATION MASTER FILE RECORD INFOOMATIO F 'M� IV <br /> ED <br /> "MFR"-GREEN FORM? 0 ?OiE <br /> DATE <br /> SHADED AREAS FOR END USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER]RESPONSIBLE PARTY INFORMATION: CHECK IF <br /> PROPE�NAME <br /> r - D r <br /> !� r t ryl��i r7 Y r PHONE <br /> OWNE <br /> BUSINESS NAME 1 •� _ 4` <br /> I rvl e✓A CC- E-MAIL ADDRESS <br /> OWNER HOME ADDRESS ATTENTION:oRCARE OF(OFrIONAL) <br /> CrTY <br /> STATE ZIP <br /> OWNER MAILING ADDRESS <br /> 1 S> C en Tr% s r <br /> MAILING ADDRESS CITY .STATE'/IrT ZIP <br /> _5 r�� 1, r�� � 45Z Qi , <br /> CORPORATION ❑INDIVIDUAL E]PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> ENVRgNME TAL ❑ EHDLocALVOLUTARY RWQCBLEAD— ❑ RWQCBLEAD— <br /> ASSIESSMENT CLEANUP COgBg-CTIVE ACTION WATER QUALITY(WDR) ❑ DTSC LEAD ❑FED EPA LEAD <br /> Z-' 2950 2953 sz�960/352613527 2965 2959 2954 <br /> FACILITY FILE:COMPLETE BUSINESS 1 SITE/PROJECT INFORMATION: <br /> IS THIS A NEW 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 �K No ❑ <br /> BUSINEWFACILrTYlSrr ROJECT NAME} J <br /> -._.- 11 UI C t'►'i< APN:r / V <br /> I C: � 1 C> <br /> SITE ADDRESS 1 PROJECT LOCATION �j (� i, / 1_ / BUSINESS PHONE <br /> 36 <br /> �— Z 15 YV , �d\[i � �Y� V�cn <br /> CITY C If 4 <br /> STATE ZIP <br /> ol <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE <br /> KEY1 iKEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS q <br /> CITY <br /> 17 <br /> MAILING ADDRESS CITY STAT ZIP <br /> � �5 ZEE, <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 ATTENTION:ORCARE OF(OPT/OVAL) <br /> MAILING ADDRESS <br /> PHONE <br /> CITY <br /> STATE ZIP <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER FACILITYIBUSINESS❑ THIRD PARTY BILLING❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner, Operator,Authorized Agent, <br /> or Responsible Party and I 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 be 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, Authorized 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) 1 f fSIGNATUR <br /> TITLE � 'C C <br /> . AXID# � l/! 3 <br /> FA* OWNER 10 0- ACCOUNTS: ASSNiNED TO: <br /> OU/002-1 1-7 3a <br /> PR*: <br /> -?2D5-q-(JS��— ACCOUNTING COMPLETED SY: � / <br /> GATE: <br /> 9-3-2015 <br /> Site Mitigation MFR 29- r <br />