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SAN.JRUIN COUNTY ENVIRONMENTAL HEALTH OARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM OCT 16 RECD <br /> "MFR"-GREEN FORM <br /> DATE 10-16-17 SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHEcRiFowNERIs CURREHTLYOHF/LEw/TH EHD <br /> PROPERTY PHONE <br /> OWNER NAME IRsiI M, I LAST 619,595,0202 <br /> BUSINESS NAME DANNIS WOLLIVER KELLEY E-MAILADDRESS <br /> KSAMAN I EGO@DWKESQ.COM <br /> OWNER HOME ADDRESS 7SO B Street,Suite 2310 ATTENTION:ORCARE OF(avnoRAL) <br /> Cm SAN DIEGO,CA ZIP 92101 <br /> OWNER MAILING ADDRESS <br /> MAILING ADDRESS CITY STATE ZIP <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> X ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD— ❑ RWQCB LEAD— ❑ DTSC LEAD <br /> [I FED EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITV(WDR) 2959 2954 <br /> 2950 . 2953 2960/352613527 2965 <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BYTHE ENVIRONMENTAL HEALTH DEPARTMENT? YES X❑ NO ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT NEW SCOPE OF WORK? YES ❑ NO X❑ <br /> BUSINESS/FACILITYISITEIPROJEm NAME 455 E.ELEVENTH STREET APN: 233-370-07 <br /> SITEADDRESSIPROJECT LOCATION 455 E.ELEVENTH STREET BUSINESS PHONE <br /> CRY TRACY,CA STATE 7JP95376 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEW/ KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS <br /> MAILING ADDRESS CRY STATE ZJP <br /> SICCODE COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINES9NAME TERRAPHASE ENGINEERING INC. ATTENTION:ORCARE OF (aPnoNa) <br /> MAIUNG ADDRESS 1404 FRANKLIN STREET,SUITE 600 PHONE 510.645.1850x102 <br /> CITY OAKLAND,CA - STATE zIP 94612 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNE4 - FAC/ USINESS❑ THIRD PARTY BILLING❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 4 the undersigned Applicani,certify that I am the Owner,Operator,AuthorizedAgent,or <br /> Responsible Party 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 ACCOUNTADDRESE 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 tome O pFe ntatfve. <br /> APPLICANT NAME(PLEASE PRINT) �((�' / ` ,� (7r / SIGNATURE <br /> TITLE f- TAx ID# <br /> FA 9: IjG'�.�-uf'� OWNERIO#:OI. I�,�Y �Q ACCOUNT#: IIQ�N, Q A9310NEDTO: <br /> PR#' 20S 2110 ACCOUNTING COMPLETED W: DATE: <br /> SRTYPE PE (SC FEEINFO AMTREMITTED I CHECK# I RECVDBY I DATE SERVICE REQUEST# I INVOICE# <br /> Rol- tis KL� 3 01'5"1 iC q-00 ti12k0 <br /> SiteVi anon MFR 29XXX 6-1-2017 <br />