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SAN. _AQUIN COUNTY ENVIRONMENTAL HEALTH ur-PARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE to l 6 Its SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECKwOWNER/S CURRENT[YON FILE W/TH EHD <br /> PROPERTY PHONE <br /> OWNER NAME FIRST 1 AST (z 0 9) 4 6$ - L}--10 0 <br /> BUSINESS NAMEE-MAIL ADDRESS <br /> SToCkToN METRQ?0LtTAN AtRPoRT dvas ti C7- 5 ov, Dr <br /> OWNER HOME ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> CITY STATE zip <br /> OWNER MAILING ADDRESS 5000 C AlI pkp 0 p+ t• WA"( <br /> MAILING ADDRESS CITY S T o C k T O N 1 STATE C A zip /O 5 10 <br /> El CORPORATION El INDIVIDUAL ❑PARTNERSHIP GOVERNMENT AGENCY El RESPONSIBLE PARTY ARTY ❑OTHER <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY Y RWQCB LEAD— ❑ RWQCB LEAD— ❑ DTSC LEAD ❑FED EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2954 <br /> 2950 2953 296 3526/3527 2965 <br /> FACILITY FILE:COMPLETE BUSINESS/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 No ❑ <br /> BUSINESS/FACILr YISREIPROJECT NAME APN: <br /> sTockToN METRO g1RPoEtt FORMER FUEL R I_+ 60 - 3t} <br /> SITE ADDRESS I PROJECT LOCATION BUSINESSPHONE <br /> 5000 S. AIRPORT WAY 2o9 68 - ,t 00 <br /> CITY S T O C k r o N STATE A "P 9 5 2 0 6 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY') I, y KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS S A M E AS F A C t L t T Y A D It G S S <br /> MAILING ADDRESS CITY 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 R A M/t Cs E E N V l R O N M E N T A L (N C . ATTENTION:ORCARE OF (OPTIONAL) <br /> MAILING ADDRESS P.O. <br /> G O% 1 D 3 5 PHONE ( <br /> 1 r\ q r 1- -f'Z <br /> -5 <br /> CITY RENO v STATE �1\`, T 7 zip V 7? 5511 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ 1`TVHIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACICNOWLEDGMENT: 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 /> T11S , PN RCAMAC-E <br /> APPLICANT NAME(PLEASE PRINT) R A M A W I- E.N V t P%o N M E tr T A L I (�C, SIGNATURE <br /> TITLE TAxID# <br /> CoKroRATtoN PREStdENT 6 $- 0566803 <br /> FA#: OWNER 10#: ACCOUNT#: ASSIGNED TO: <br /> PR#: SO ACCOUNTING COMPLETED BY: DATE: <br /> L!iL <br /> 9-3 2015 A 00 A44 /`CtJ/C�� ZW 51- _Z siz oa 7�sz.3 <br /> Site Mitigation MFR 29- <br />