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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE Z J I-4- SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CAwx rOwmmCuRRaxrtravrxx*m EHD <br /> PRorEN" PHONE <br /> OWNER NATE IRST A ST V- g <br /> E•flY1L ADORE6t1 <br /> StnlnEss' J L&S M tA.yi FAKAIAUtil <br /> OWNER HONE ADolus IVl�` K✓ ATTemoN:ORCARE OF(anawc) l DLA <br /> CITY /', STATE C? ZIP ZU d <br /> OWNERlMAawo'(eAmir." <br /> MAa aADOwnCm STATE Zr <br /> ❑CaRr "M ❑WWWAL ❑PARTNERMW ❑GweaENT AGENm ❑RnmMISLE PARTY ❑OT"Ot <br /> 191'ENVIRONMENTAL ❑ EHD LocAL VOLUNTARY ❑ RWQCB LEAD- ❑ RWQCB LEAD- <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) ❑ DTSC LEAD ❑FED EPA LEAD <br /> 2950 2953 2960/3526/3527 2965 2959 2954 <br /> FACILITY FILE:COMPLETE BUSINESS/SnW PROJECT INFORMATION: <br /> [ISTHIS A NEW PROJECT LOCATION Ir TPREVIOUSLY REGULATED BY THE ENVNtONmENTAL HEALTH OEPARTUENT? YES ❑ No ❑ <br /> IS AN E>OSTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES No ❑ <br /> 6U81NF8IFACI1UIYIffEIfV LwzcT NAME `N�( .0 'IU!�F' I <br /> AM: V-111- <br /> -may— )J <br /> `077`70`077439 <br /> TTEAD077/PROJECTLDCATNIN /I 3 T BUesms LPHONE7 <br /> `C STATE C .Lr RJ.7 <br /> BOARD or SUPMV* R DIST LWATlal CODE KE11 K-21 <br /> MA&m ADOREas,F orF awu FROM FACILmf Acomm <br /> MAawo Ammo Cm STATE ZIP <br /> SIC CODE COWMw' <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPON8 eu PARTY IDENTIFIED ABOVE. <br /> SuammNAale } Yfine�✓ 1bt >'l -St 1�.1'� ATmmou:c*CAREOF(cpnwm.) <br /> MAaiNe ADOREss PHONE <br /> CITY STATE ZIP <br /> ACCOUNT ADDRESS TO SENO FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING <br /> BiLLTNG AND COMPLIANCE ACKNOWLEDGMENT: 1, the undersigned Applicant,certify that I am the Owner, Operator,Authorized Agent, <br /> or Responsible Party and I acknowledge that all PERM1T FEES,PENALT/FS,ENFORCEMENT CHARGFS and/or HOURLY CHARGF_S associated <br /> with this project will be billed to me at the address identified above as the ACCOU.vTADDREss 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 /> JOAQUTN 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, 1 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 /> Amur u/T NAS(pPLrEAM PaNr) �Ja )k-&V) M a1w 1'N &0—Y-4AI\ -- <br /> TAX ID! <br /> FAS', OWNER 0 il: AOCOUNT♦1: ASSMED TO: <br /> M II; ACCOUNTING OOyry,ETIED MY: DATE; <br /> SR TYPE PE I SC FEE INFO AMT REMITTED CHECK# RECV D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan 2903 523 $456.00 <br /> 2904 1 523 $760.00 <br /> Site Mitigation MFR 29-XXX 8-1-2017 <br />