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0 • SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION MASTER FILE RECORD INFORMATION FORM "MFR"-GREEN FORM DATE 1) I SHADED AREAS FOR EHD USE OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHZQTa'O*WER18CUfiR9Mr0RFE*MEHDE1 PROPERTY h elA, PHONE ( OWNER NAME IRST /♦/ c-> Si 31p , BuISSE99 NAME Fe or,u L/-yf T -' t b 1-'n LADDRE88 _ - LLC w p�ule;nG kw OWNER NONE ADDRE89 aSsti 1 / / �TJN �1` 7.r7 AilEHT10N:ORCARE OF OPF)ONV.J crry r l v S J1J V Cin -JOa� STATE LP �OZ OWNER MAILING ADDRESS / `rl 1 1 ICT` 3�n / c , ) Z MAILING ADDRESS Cm �.IoS �/ I�-W'05- lI�V J V� STATE C./L LP [I CORPORATION ❑INDMDUAL ❑PARTNERSHIP ❑GOVERNMENT Aaaw ESPONSNLEPA G..L� ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY XRWQCB LEAD- ❑ RWQCBLeAD- ASSESSMENT CLEANUP CORREGTIVEACTION WATER QUALITY(WDR) ❑ DTSC LEAD ❑FED EP ALEAo 2950 2953 2960/3526/3527 2965 2859 2954 FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: ISTHISANEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BYTHE ENVIRONMENTAL HEALTH DEPARTMENT? YESX No ❑ IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ NO BUSINESS/FACRRY/SREIPRwECT NAME lrA JI/�p /��,j� J�,G�1� APN: SITE ADDRESS I PROJECT LOCATION © f�f Y" Igel /'�l v� BUSWEBSP�E C� /Dov Cm �. �I� STATE,^ zip BOARDOFSUPEINISORDISTRICT LOCATION CODE KEPT KEY2 r MAMINO ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS I f MASJNG ADDRESS CRY GC /JJ-�/p� �J STATE 4 MP A1C ? SIC CODE COMMENT: c U"` / (/ THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME ATTENTION:ORCARE OF fOPIIONALJ MAILING ADDRESS PHONE CRY STATE ZIP ACCOUNrADDRE99 TO SEND FEES AND CHARGES: OWNER❑ FACILfN/BUSINESS❑ THIRD PARTY BILLING[] BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner, Operator,Authorized Agent, or Responsible Parry 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. APPLICANT NAME(PLEASE PRINT) (7144 ra1f IS.P JD,~11 LL� SIGNATURE TITLE W ti rrQ �ei� �na TAKIDGI K f� 3q 3 YTS FAR: -�Q,u3iZ-J OWNERID>F: J�, I ^� ACCOUW*XA "E-7 (l A/�IO- A88IONED TO: ACCOUNTNOO(COJ�MPLETED SY: J � KIN ll �" DATE: 9-3-20155 U !S