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San Joaquin County Environmental Health Department <br /> DATE 2/18/2015 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> 5HADEQARRI<A1 FOR..EH"Q C ONLY i <br /> - I OWNER IDN CASE N UNIT IV <br /> OWNER FILE:CoMpLETEPROPfERTY OWNER/RESPONSIBLE PARTY INFORMATION: CRECK/F OWNER CURRENTLYONF/LEwITH EHD � <br /> PROPERTY OWNER NAME Matt Davis 800)424-2002.ex.2021 <br /> Fitsf MF Last PHONE NUMBER <br /> BUSINESS NAME i KQ Corporation-Redding Auto Center E-MAIL ADDRESS <br /> McDavis@LKQCorp.com <br /> Owner Home Address <br /> 2850 Viking Way <br /> City STATE ZIP <br /> Redding CA 96003 <br /> Owner Melling Address <br /> 2850 Viking Way <br /> Mailing Address City Stets Zip <br /> Rcdding CA 9ti01; <br /> ®CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_X_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> FACILITY 10 N INV# Wcy4j?,71 <br /> ccouNT ID PR W RO# AssHSNED EMPLom LEAD AoENcY:EH D Y R W QCB_OTSC_EPA_ <br /> VAo0u29 -?kD5-3?B .10 I/AAlq <br /> FACILITY FILE: COMPLETE BUSINESS/SITIE/PROJECT/NFORMATIoN.- <br /> Is this a New Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an EXISTING Project LOCATION but a NEW SCOPE OF WORK? YES ❑ NO ❑ <br /> BUS INEssIFAOILnrISrrEIPROJeeT NAME LKQ#785,SRA Project <br /> SITE ADDRESS/PROJECT LOCATION SUITE$ BUSINESS PHONE <br /> 2041 Navy Drive 209-235-4334 <br /> CITY STATE ZipStoci pR <br /> CA 95206 <br /> BOARD OF SUPERVISOR DISTRICT / LOCATION CODE i KEY11 KEV2 <br /> Mailing Address IfDIFFERENTfromFacllltyAddrms Attention:orCare Of(optional) <br /> Melling Address City STATE LP <br /> SIC CODE APN N COMMENT: <br /> Ile /C-- <br /> THIRD <br /> C---THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Responsible Party identified above. <br /> BUSINESS NAME NA Attention:orCare Of (optional) <br /> --T- <br /> Mailing Address PHONE <br /> CITY STATE LP <br /> Arrr)uA/TAOORFsy for fees and charges OWNER FhCQxMeV& K Ay{AMK11It $ttg,}x( <br /> BILLING AND CO\IFLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent,or Responsible Parry and I acknowledge that all Pewter FEES, <br /> PENALTIES,ERF0RC5VrNTC1L4RGEs and/or 110VRLYCRARGEY associated with this project will be billed tome at the address Identified above as the AcCouiyrAOORF.SS for this site. 1 also certify that all <br /> information provided on this application is true and correct;and that all regulated activities will be performed In accordance with all applicable SAN JOAQUIN COUIVrV Ordinance Codes and/or <br /> 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 <br /> 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 <br /> Is available and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) Matt Davis SIGNATURE <br /> TITLE Plant ManTax ID# <br /> ager <br /> Approved By Data Aecouribng Office Processin Complated By Date <br /> SITE MITI-G�A?ITION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT N CHECK N RECEIVED BY WORK PLAN PE <br /> FEE:f tJ 0 2(-'�� <br />