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0 <br />0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE <br />eD°WBIwmiu darrEaADMOTNAMe Super Store Industries <br />SHADED AREAS FOR EHD USE <br />OWNER FILE : COMPLETE PROPERTY OWNER/ REBPONBiBLE PARTY INFORMATION: Cm=,Ow mCu Arvnrcwrur" EHD El <br />PaDIrmY <br />DrINeANAtc <br />Scott Sommerfeld <br />P" <br />209-858-3384 <br />.1 „ <br />Super Store Industries <br />I ssomMrIfeld ssica.com <br />Owae1H AOMmeArnsnoN:d,GAAa OF(oRnouW <br />16888 McKinley Avenue <br />RTA- CA z,P 95330 <br />or" Lathrop <br />16888 McKinley Avenue <br />1111 10A0caess°^ Lathrop "TATE CA LF 95330 <br />®CaaraaATnN ❑annmwL ❑PowHessIM ❑ OovWAIeNrAdeMm ❑Raaroll PAKIY ❑Gn2A <br />1ff ENNRONIfilei <br />ASSESSMENT <br />2980 <br />❑EHD LOCAL VOLUNTARY <br />CLEANUP <br />2853 <br />❑ RWQCB LPaO— <br />CORPECTNE ACTION <br />2960/352fJ3527 <br />❑ RWQCBLEAD— <br />WATER QUALITY (WR) <br />2968 <br />❑ DTSCIEAD <br />2988 <br />El FM EPA LEAD <br />2954 <br />A-AwU ITV FILE- COMPLETE SLIVNESS 1 r41TF/ PRrLIFM INIXN2MAT1nN- <br />-IS THISANEW PRc EOTLOCArON NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARnWNT? Ye119 NO ❑ <br />to THIS AN Sayn i PROJECT LOCATION, BUT A NEW SCOPE OF WORK? Yes ❑ No <br />eD°WBIwmiu darrEaADMOTNAMe Super Store Industries <br />APR: 198-160-26 <br />RITE 001�iB1P"O �TLAO"T°" 16888 McKinley Avenue <br />AOCDUNnaOOCYA{NaO aY: <br />°rtv Lathrop <br />8TA1e CA"' 95330 <br />eaAoar &NeawLOROI°n'= I LOareNOme Ned <br />Nola <br />M.W Np boll�e . IF m rrmlBlr nmM FI Ram bw1FSe <br />MAUNDAmaeasOGY <br />STAT[ Zs <br />Oleo= SMT <br />THIRD PARTY BALLING INFO: COMPLETE IF BIWt/O PARTY IS DIFFERENT FROM PROPERTY UWNER OR NESeWHRUae FA l T,Len,Irlru Awvc. <br />a-- Krazan & Associates, Inc. I ATTsunwi: WGAAeoF Michael Bowery <br />"WUNO"°°"°°° 215 West Dakota Avenue P"°"" 559-348-2200 <br />STATE CA AP 93612 <br />C- Clovis <br />ADGDUMADDIIOa TGm DT ANOOHNIOW: OWNER❑ <br />FAcatryiBusums❑ THIRD PARTY BILLING® <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 PEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated <br />with this project will be billed to me at the address identified above as the ACCot1NTADDRESS for this site. I also certify that all information <br />Provided on this application is true and correct; and that all regulated activities wig 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 N is provided to me or my representative. / <br />Arru HAaatwruepmwo Scott Sommerfeld <br />TAe ma <br />Tma Facilities Manager _ <br />FAR n <br />FiQO <br />CAttaT,OY.�WDOZLY[l AoeCW"r a: <br />AuaN1�TU. <br />III �.��� S <br />AOCDUNnaOOCYA{NaO aY: <br />OAIa. <br />9-3-2015 <br />Site Mitigation MFR 29- <br />