Laserfiche WebLink
BUSINESS NAME 4144. e In isitio.ci 6 roue, 1, C. <br />MAIUNG ADDRESS <br />19177 Cqpi+ct I Svi%fe 103 <br />ATTENTION: OR CARE OF (0P770NAL) 01 3o <br />PHONE ct s 7 3 53314 <br />Cm <br />orokct <br /> STATE <br />C A <br /> ZIP q <br />2. 7po <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br />OWNERG <br /> <br />FACILITY/BUSINESSID <br /> <br />THIRD PARTY BILLINGS'''. <br />77 - <br />t., <br />Work Plan <br />FA #: ,-i <br />frAvo 24 )2_3 <br />OWNER ID #D• . i <br />(A.)00--2 Z )-1-D <br />ACCOUNT #: <br />420{Dy4g3.---7 ASSIGNED To: <br />PR #: <br />PKOS-41-7--D2-40 <br />ACCOUNTING COMPLETED BY: <br />/ii0 <br />DATE: ,6 4, <br />,-.5 <br />,./..„.., <br />7 <br />, <br />/ ) 1 <br />SR TYPE FEE INFO AMT REMITTED CHECK# RECVD BY DATE SERVICE REQUEST# INVOICE# PE SC <br />2903 <br />2904 <br />523 <br />525 <br />$417.00 <br />$695.00 <br />SAN J- 'QUIN COUNTY ENVIRONMENTAL HEALT*PARTMENT <br />SITE MITI_ATION MASTER FILE RECORD INF .. ATION FORM <br />"MFR"- GREEN FORM <br />DATE O'/!t. /2417 SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: <br />CHECK IF OWNER IS CURRENT1Y ON FILE WITH END <br />PROPERTY <br />OWNER NAME <br />PHONE <br />g 10 -.1 Li 0 -c2.115 FIRST MI LAST <br />BUSINESS NAME <br />\Affc4-c0 re jr AT AIN1 CO() r•i j LL C E-MAIL ADDRESS storro4(Dwa-core. tie- <br />OWNER HOME ADDRESS g o S ATTENTION: OR CARE OF (OPT7ONAL) 1 Li 44% sf sfe, 300 ) STATE C 4 ZIP lig i .2 <br />c" 04 t< 1 qn <br />OWNER MAILING ADDRESS <br />MAIUNG ADDRESS CrrY STATE ZIP <br />0 CORPORATION <br /> <br />0 INDIVIDUAL <br /> <br />SCARTNERSHIP <br /> <br />0 GOVERNMENT AGENCY <br /> <br />0 RESPONSIBLE PARTY <br /> <br />0 OTHER <br />1;1. ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />• EHD LOCAL VOLUNTARY <br />CLEANUP <br />2953 <br />III RWQCB LEAD - RWQCB LEAD - DTSC LEAD <br />2959 CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />III FED EPA LEAD <br />2954 <br />FACILITY FILE: COMPLETE BUSINESS / SITE/ PROJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES 0 No <br />IS THIS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES Er No 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME <br />I 61 27 A (fill Cour+ APN : 163 3 y 0 - 03 <br />SITE ADDRESS / PROJECT LOCATION <br />1 2 1 Army CovrA- BUSINESS PHONE <br />Crry S +pc k -1-ori STATEc A ZIP ci. s. 2. 06 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEy1 KEy2 <br />MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS <br />MAIUNG ADDRESS CM 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 />BILLING 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 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 ACCOUNT ADDRESS 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 S'I'ATE 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 m representative. <br />APPLICANT NAME (PLEASE PRINT) 1-t10 VISCtift Va#140/// <br />SIGNATURE <br />1,1 <br /> <br />TITLE Gie,010 <br />TAX ID # <br />.% <br />9-3-2015Site Mitigation MFR 29- XXX 10-26-2015