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SANOQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> SHADED AREAS FOR EHD USE <br /> DATE 2/1/18 CHECK IF OWNER IS CURRENTLYON FILE WITH EHD <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: PHONE 510-398-9956 <br /> Deo <br /> PROPERTY Eric AST <br /> IRST E-MAIL ADDRESS <br /> OWNER NAME edeo nr, pyinti-rng.co <br /> BUSINESS NAME Exeter Louise Land, LLC <br /> ATTENTION:OR CARE OF(OPTIONAL) <br /> OWNERHOMEADDRESS 101 Elm Street, Suite 600 STATE PA ZIP 19428 <br /> Cm Conshocken <br /> OWNER MAILING ADDRESS 2001 Broadway, Suite 150 STATE CA z,P 94612 <br /> MAILING ADDRESS CITY Oakland <br /> �T,,�prAKINERSITY' El GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> ❑COWORATKNI <br /> ❑INDMDUAL <br /> RWQCB LEAD- ❑ RWQCB LEAD- ❑ DTSC LEAD ❑FED EPA LEAD <br /> CX ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY 2959❑ WATER QUALITY(WD)RI <br /> 2954 <br /> CLEANUP CORRECTIVE ACTION <br /> ASSESSMENT 29601352613527 2965 <br /> 2950 2953 <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: YES No ❑ <br /> L <br /> EW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ($ <br /> EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? AEN. <br /> AcamISTrTJPROJEcTNAME Longhorn Portfolio 198-110-14 <br /> BueI�ePHONE 510-398-9956 <br /> SS I PROJECT LOCATION 2325 West Louise Aveneu <br /> SATE C A� 95330 <br /> CITYanteca <br /> UPEIMBDR DISTRICT <br /> LOGTKkI CODE KEY1 KEY2 <br /> DRESS,IF DIFFERENT FROM FACILITY ADDRESS <br /> STATE ZIP <br /> MAILING ADDRESS CITY <br /> SIC CODE ' <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BuawEss"A'� Nova Consulting Group, Inc. ATrrEw m:agC,�OF <br /> MAILINGADDRESS 1107 Hazeltine Blvd., Suite 400 <br /> PHONE 4�- =~_ 1355 <br /> CTT' Chaska STATE MN 55318 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: O W NER'Y F A x—•BUSINE',;.:: illillilillilllllllllilljlll <br /> THr n�q-v BILUNG(X <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant_certify tw I zm <br /> the Owner, <br /> or Responsible Party and I acknowledge that all PERAHT FErs,PENALT/ES,E.�F"R(EMEK)q�ES and/or Ho��l� -4uthork"d ��rrrr• <br /> with this project will be billed to me at the address identified above as the ACCot'Ynp,� for this site• H9RGES associated <br /> information provided on this application is true and correct: and that all regulated acies Rip be pe this l also certift that all <br /> applicable SAN JOAQI IN COUNTY ORDINANCE CODES and or STANDARDS and ST.4TF, al- FEDE Performed in accordance Tr,ith all <br /> undersigned Owner, Operator, Authorized Agent, or Responsible Party for the project lo{ abut Ran Laws and REGI L,�T►oNs, <br /> gn p g Po a under facility- ;' A-� the <br /> authorize the release of any and all results, reports. and other environmental asstnt info rte address, I hereb% <br /> ENVIRONMENTAL HEALTH DEPARTME, T as soon as it is available and at the same time it i�id o Information to S"' JOAQI�IN CO(\T <br /> APPLICANT��NAME(PLEASE PRINT) A eine e, {1 111 n -Inc, SIGNATURE IL or m. representative. <br /> TITLE 9fry ,dr I r,\ a TAXIO# 7 <br /> FA#: O L,r u`� OWNER ID#: ACCOUNT#: <br /> ^NrGNED TO: <br /> PR#: ACCOUNTING COMPLETED BY: <br /> �-f DATE; <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DI <br /> 2903 523 j '$ 0 SERVICE REQUEST# <br /> Work Plan 2904 523 $650.00 L 6 ��7.S j INVOICE# <br /> 9-3-2015Site Mitigation MFR 29-XXX 6-2-2017 <br />