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SAN J,- _.JUIN COUNTY ENVIRONMENTAL HEALTH L ARTMENT SITE MITIGATION MASTER FILE RECORD INFORMATION FORM "MFR"- GREEN FORM DATE 7-Z 4-/` SHADED AREAS FOR EHD USE OWNER FILE:COMPLETE PROPERTYOWNER/RESPONSIBLE PARTY INFORMATION: CHECKIFOWNERIS CURRENrLYONFILE WITH EHD PROPERTY PHONE OWNER NAME %+- MI VS1 BUSINESS NAMEA j� '/G nr`/ /(// i E-MAIL ADDRESS 7 P` /17/ /({ a, �P A`�iGiA ! Gr�.+� Ani OWNER HOME ADDRESS ATTENTION:ORCARE OF(OPTIOWAL) CRY STATE LP OWNER MAILING ADDRESS MAILING ADDRESS CITY nSTATE ZIP ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY RESPONSIBLE PARTY ❑OTHER ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD- XRWQCB LEAD- ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) [:1 DTSC LEAD E)FED EPA LEAD 2959 2954 2950 2953 296013526/3527 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 o IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES No ❑ BUSINESS/FACILFTY/SFTE/PROJECT NAME ! 1�r n n ,/d 3v APN: SITE ADDRESS/PROJECT LOCATION 4 BUSINESS PHONE CITY 5 71 GIC'fed STATE i4 ZJP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 `T/ MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS 110Z.42 1UZ J ryv G`N��/ D A'�v� 0 WD MAILING ADDRESS CITY C 02D➢VA' /� STATE ZIP 9S G 70 SIC CODE COMMENT: THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME M/f ATTENTION:ORCARE OF��BPT/DAWLJ MAILING ADDRESS �et L/rJf'f"W Dtp6e GpgrT � fy " 04" PHONE CITY RF7�w � /" STATE i6 zip g5-G7 ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ "THIRD PARTY BILLING BILLING AND CONIPI,IANC'E ACKNOH7.EDGMENT: I,the undersigned Applicant,certify that I am the Owner, Operator,Authorized:9gent, or Responsible Party and I acknowledge that all PFRA4HT FFFS, PENALTtFS,EATORCEVENT CHARGES and/or HoiW1.I CHARGES associated with this project will be billed to me at the address identified above as the ACC0L%,N'T,41)1)RFSS 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 COUNTI ORDINANCE CODES :and/or STANDARDS and S'I ATE 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 COITNTN' ENN7RONMENTAL HEALTII DEPARTMENT'as soon as it is available and at the same time it is provided to me or m1'representative. ,foeweis 61.S,,.�✓G. APPLICANT NAME(PLEASE PRINT) V*"Y.1 SIGNATURE TITLE ('0,0 jf TAx ID# 57—9 3 FA tl: OWNER ID 0: ACCOUNT C ASSIGNED TO: PRM: ACCOUNTING COMPLETED BY: DATE: 9-3-2015 Site Mitigation MFR 29-