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SAN OQUIN COUNTY ENVIRONMENTAL HEALTHWARTMENT ! <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORIWIi�� <br /> "MFR"-GREEN FORM �S/J <br /> DATE 1011912017 0 D A!!// EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK/FOHMER/! REHrcrON� EHD E] <br /> PROPERTY I PHONEtop PIPFINTL <br /> OWNERNAME FIRST MI LAST <br /> Su9INE89Nme SAN JOAQUIN LUMBER COMPANY,ACAUFORNMCORPORAMON EMAILAODNESS JOE_EUPHM ANOO.00M <br /> OWNER HOME ADDRESS ATTENTION:ORCARE OF(OPl10N4L) <br /> CRY STATE ZIP <br /> OWNER MAILING ADDRESS 901 BLRTEwIELD ROAD <br /> MAIUNGADDR C" San Anselmo STATE OA Zip 94960 <br /> Ary❑CORPORATION INONIMAL ❑PARTNERSHIP ❑GGYEaNMENTAGENOY ❑Rin;MWISLE PART ❑OMPA <br /> yy ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD- ❑ RWQCB LEAD- ❑ DTSC LEAD [1 FED EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2954 <br /> 2950 2953 29601352613527 2965 <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: yy,, <br /> ISTHIS A NEW PROJECT LOCATION NOOTPREVIOUSLY REGULATED BYTHE ENVIRONMENTAL HEALTH DEPARTMENT? YES�I No <br /> IS THIS AN EXISTING PROJECT LOCATION,BUTA NEW SCOPE OF WORK? YES ❑ NO Ix <br /> BU8WE891FAGLRYBDFIPRQIECT NAME APN: <br /> $READOREMI/PROJECTLOCATON 465EAIn ELEYIRTMSTREET BU8INE99 PHONE <br /> CRY TNAa STATE LP 95201 <br /> BOARD OF SUPERVWOROISIRIOf LOCATION CODE KV1 KEY2 <br /> MAILING ADDRESS,IFOIFFERENTFROM FACILITY ADDRESS <br /> MNLINGADDRESSCRY 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 /> BU81Nsaa NAME Terraphase Engineering ATTENRDN:ORCM F(oPnoHAQ <br /> MAIDNGADDREae 1404 Franklin St#600 PHONE x <br /> Cm' Oakland STATE CA 'JP 94612 <br /> ACCOUNTADORESS TO SEND FEESAND CHARGES: OWNER[] FACILTTYIBUSINESS❑ THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent,or <br /> Responsible Pan),and I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with <br /> 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 Owner, <br /> Operator,Authorized Agent,Or Responsible Pnrly for the project located above under facility/site address,I hereby authorize the release of <br /> any and all results, reports, and other environmental assessment information to SAN JOAQUIN CO ENVIRONMENTAL HEALTH <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> APPuoANr NImE(PLEASEPRINT) Nicole Gregory SIGNATURE `:. �1 <br /> r <br /> TSE TMID# <br /> FAM: v-T✓1.� OWNERroR o ApOOUNfRIk QO wso ABBiONEOTo: E <br /> PRM: u LY I t"I ACCOUNTING O0WUIT®BY: rT G-. DATE: <br /> SR TYPE PE / SC FEEINFO AMT REI9TTED CHECWI RMYDBY DATE SOMCEREQUEST# INVOICE# <br /> Work Plan 2903 523 $456.00 �' b VIS(/Z5 /0 t0 11 S Q'"V <br /> 2904 1 523 1 $760.00 <br /> Site Mitigation MFR 29-XXX 8-1-2017 <br />