SITE INFORMATION AND CORRESPONDENCE

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RECEIVED SAN*UIN COUNTY ENVIRONMENTAL HEALTH ISARTMENT ,JUN 3 p 2016 SITE MITIGATION MASTER FILE RECORD INFORMATION FORM "MFR"-GREEN FORM ENVIRONMENTAL DATE 0 — O — Z o SHKO#ff AWXPP0R,-XkTN7l3E OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION. CHECK IF OWNER IS CURRENTL Y ON FILE wim EHD PROPERTY ;-VA ` � PHONE n OWNER NAME FIRSITT Ml J LAS Z V c �' ( y O O BUSINESS NAME C �A % E-MAIL A4 ES 'ZVZ 0-6 r_1/.Cp OWNER HOME ADDRESS -f 7 Qi M I,+ ^ v^ ATTENTION:ORCARE OF(OPTIONAL) W�y�} CITY A A c- i• \ STAT ZIP OWNER MAILING ADDRESS'_1 K• MAILING ADDRESS CITY STATE ZIP ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY RWQCB LEAD— ❑ RWQCB LEAD- ASSESSMENT CLEANUP 'CORRECTIVE ACTION WATER QUALITY(WDR) ❑ DTSC LEAD E]FED EPA LEAD 2959 2954 2950 2953 2960/3526/3527 2965 FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: 111...sss IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No Ily, IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES A No'❑v BUSINESS/FACILITY/SrrEIPROJECT NAMEI APN: ZwJ SITE ADDRESS/PROJECT LOCATION Z 0 w• /►x IC' BUSINESS PHONE CITY /��v C ' STATE ZIP J BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYS KEYZ MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS MAILING ADDRESS CITY STATE ZIP SIC CODE COMMENT: THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME P- VCO -,�^v,rco• w l L t• ATTENTION:ORCARE OF (OPTIONAL) MAILING ADDRESS C�A-w A ^ I, /� PHONE /US �O 6 - �J` w too %J_ l7nY a7 40IL J 'J STATE COC) 1ZIP _1 V�^��i/ v -rW ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER[-] FACILITY/BUSINESS❑ THIRD PARTYBILLINGf BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner, Operator,Authorized Agent, or Responsible Party 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 PRIr m NT) Cv t/, A,,- SIGNATURE Z------- TITLE I9r D 1 Is. ` I" J►A ^A<"Z— TAx ID# FA#: OWNER ID#DU .lACCOUNT#: A ^ ASSIGNED TO: PR#: f� � ACCOUNTING COMPLETED BY: L, �/S(I / ` w/ DATE: -7/ ?h 0 a--r, I 9-3-2015 Site Mitigation MFR 29-