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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE <br /> MASTER FILE RECORD INFORMATION"MFR') GREEN FORM <br /> ���u �i3 <br /> SITE MITIGATION <br /> `�&/SLOP <br /> SHADED AREAUS FOR END U19 ONLY OWNER IDS �-9 CASES SRcnG-�8 UNIT t <br /> OWNER FILE:COMPLETE PROPERTYOW``NERCC/RESPONSIBLE PARTY INFORMATION: rHecRtvomERla CURREraYMPR.EWffn EMD <br /> PROPFRIYOWNER NAME �shCU\h T'f0 'w��J LID UD (zCl) 47)8-`TZ00 <br /> FIRST Ml tAST PHONENUMSER <br /> BUSINESS NAME /' L /� 1 . &MAILADDRESS <br /> Strr S G w F rCr 11]r pe U�\OY <br /> OWNER HOMEAWRESS <br /> Cm STATE LP <br /> OWNER MMUNGADDRE39 <br /> MAmbaSADDRESSCITY Carl � � TA z'p',, ,--, <br /> M <br /> 'ORPOMTIDN ❑INDDUAL [IRT <br /> PARTNERSHIP [IGOVERNMENTAGENCY ❑RESPONSIBLE PARTY ,J L ❑/OTHER <br /> SITE MITIGATION A-ENVIRO NMENTAL ASSESSMENT_VOL NTARY CLEAN UP_WATER QUALITY_HW PIPELI NE INVESTIGATION_LO P_ <br /> FACILm ID# INV# ACCOUNTID PR91 O# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB_DTSO_EPA_ <br /> X01-1 242-Iso 3(Pq <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <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 ANEW SCOPE OF WORK? YES No ❑ <br /> BUHINESSIFACILTYISITEIPROJECT NAME <br /> STEADORESS/PROJECTLOCATWN /n7 r(� n- _ 1'' n/ SURE# BUSINESS PHONE <br /> " AJ 4 T�CrI y Atn {7��j X <br /> cm S6 C pvo Y--1 <br /> STATEOF 520'7 <br /> BOARD OFSUPERVISOR DISTRICT LOCATIONCODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILIIYADURESB ATIENTON:ORCAREOF(OPTOAALJ <br /> 2511a cmc s Pct Dr t3Sc clo L;r,c\54 Yti1 vi . �T <br /> MAILING ADDRESS CITY ` _ (�TATE 7j <br /> I 1% <br /> SIC CODE APN# Yv COMMEhr: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME 1�-n-) <br /> ATTENiDN:ORCMEOF(OPTIONAL)CtO Ltn Y YYlM c,�.\ <br /> MAIUNGADORESSPHONE <br /> 52 Nc..�orr,us � #350 2cro -112-k-237 <br /> STATE <br /> cm SG z_-rhea- o CA `15$3 <br /> AccouWADDREss TO SEND FEESAND CHARGES: OWNERO FACILITYIBUSINESSE] THIRD PARTY BILLING <br /> BILLMG AND COMPLIANCE ACINOWLEUGMENT; I,the undersigned Applicant,certify that I am the OmHeA Operrrtory AntharizedAgmeb or Respowible Prole and I acknowledge that ail FEmrIT FEES, <br /> PENALTIES,ENFORCEdrEAPCHMG£R and/or HODRtr CHMOFB associated with this project will be billed tome at the address identified above ss the AccouoTADDE£SS for this site. 1 also certify,that ail <br /> Information provided on this application is tree and correcl;and that ail regulated activities will be performed in accordance with eU appUcabie SAN JOArim COIIMY ORDINMCE CODES and/or <br /> STANDARCS and!TATE and/or FEDERAL Laws and REGU TIONS.As the undersigned lhrner,Operator,ANrhar¢edAgarq or Rerpomlble Par/y for the projectlacated above under facility/site address,I <br /> hereby authorize the release of any and all result%reports,and other environmental assessment information to SAN JO.AQUW COUNfI'ENVIRONMENTAL HEALTH DEPARTMENT as soon vs it b available <br /> and at the same time it is provided to mcor my represenmBwa \ <br /> GL-`-'\ <br /> APPLICANT NAME(PLEASEPRINT) �\naG!��/ <br /> TITLE E�-YYI TAXID# <br /> APPAOV®EY DATE FA=UN NOOMCEPROGE9nIN000MPT RWY Z � IDATE <br /> BITE MITIDATION AMOUHTPAID DATE OF PAYMENT PA.YMENTTYPE RECEIPT# CHECKS RECEIVED BY :WORK PLAN PE <br /> FEE:$ <br />