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SAN JOP ''JIN COUNTY ENVIRONMENTAL HEALTH P-OARTMENT SITE MITIG. _.ION MASTER FILE RECORD INFOK._ATION FORM "MFR"-GREEN FORM DATE 7-1`1-1` SHADED AREAS FOR EHD USE OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION. CHECK IF OWNER IS CURRENTL Y ON FILE W/TH EHD El PROPERTY PHONE OWNER NAME I FiRsT M1 LAST BUSINESS NAME E-MAIL ADDRESS Atl�i�/1iG Q�c�+7/</� a� �P� AG�iGill �r� Grp.+. R�✓ OWNER HOME ADDRESS ATTENTION:ORCARE OF(OPTIONAL) CITY STATE ZIP OWNER MAILING ADDRESS MAILING ADDRESS CITYSTATE ZIP ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY RESPONSIBLE PARTY ❑OTHER ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD- 0 RWQCB LEAD- ❑ DTSC LEAD ❑FED EPA LEAD ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2954 2950 2953 2960/3526/3527 2965 FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES 15Z_ No ❑ BUSINESS/FACILnY/SRE/PROJECT NAME rvlU►14 [Nn,,, 4- ,/4 3v APN: �/ SITE ADDRESS/PROJECT LOCATION 4 /1�p/'V � Y-I BUSINESS PHONE CITY 57141 STATE611 ZIP ?r 7/0 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYS KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS MAILING ADDRESS CITY ��. G 02DyVg" Y STATE LP 15-4,70 SIC CODE COMMENT: THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAMEkoc'qwtS 11-11111 �G ATTENTION:ORCARE OF TIONAL) y.S. A MAILINGADDRESS /o( (qP-fix XIS/' vtv'r (yf` �0 PHONE CI Y RopV7 I. �7[ J STATE ' 1 ZIP 1�- _7 1 19- ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNONVLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator,Authorized Agent, or Responsible Party and I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated 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 provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. q��gnis y.s,,.�✓o. APPLICANT NAME(PLEASE PRINT) J/Jarrlp l M � jJ SIGNATURE U / 7� J r nry Cl/ TITLE p�,/rGr ��W�1yl TAxID# 5-7 -1) 3 73 224 FA#. O O �� OWNER ID#�)'t/� ACCOUNT#: ASSIGNED TO: aj PR#: � ACCOUNTING COMPLETED BY: 1 D DATE: 9-3-2015 Site Mitigation MFR 29-