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0 0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE - al al - (� SHADED AREAS FOR EHD USE <br />OWNER FILE. COMPLETE PROPERTY OWNERI RESPONSIBLE PARTY INFORMATION: CHECKIFOWNER/SCURRENtt YONFILEWITH EHD <br />����`"`Illl.. <br />PROPERTY <br />OWNER NAME <br />A t `- - CON O A <br />kT-F- V I V <br />1 V `FIRST 9 <br />O <br />V <br />BUSINESS PHONE A t <br />,v� <br />PHONE <br />9 a5 ` (a i q- g y o0 <br />M1 <br />I <br />LAST <br />BUSINESS NAME Nsikv I,,,� PfrO kk V11* �vl� 1 1 r <br />ll 1I��VV l 1J LL+L_ <br />n , Q iI-LL LLC <br />�C51'E] LJ 1-Tq 1... L+��"'"na <br />IL ADDR S <br />:,re nutdsundbrown. <br />OWNER HOME ADDRESS N / <br />ATTENTION: ORCARE OF (OPTJON d J)ainq Pq r- r. <br />CITY <br />STATE zip <br />OWNER MAILING ADDRESS I Goo Coy K.ord Ave. Osie.- Gov <br />MAWNOADDRESS CITY conco -_I <br />STATE CA ZIP 9455 40 <br />❑ CORPORATION ❑ INDIVIDUAL RPARTNERSHIP ❑ GOVERNMENT AGENCY ❑ RESPONSIBLE PARTY OTHER <br />ENVIRONMENTAL <br />❑ EHD LOCAL VOLUNTARY <br />❑RWQCB LEAD- <br />❑ RWQCB LEAD- <br />BUSINESS PHONE A t <br />,v� <br />Om L' rAfO <br />` <br />STAT IF 9 5 330 <br />BOARD OF SUPERVISOR DIBMIOT LOOATION CODE KEY1 <br />KEY2 <br />MAILING ADDRESS, IF DIFFERENT FROM FAwLITY ADDRESS kaoo Concord a00 <br />El DTSC LEAD <br />❑ FED EPA LEAD <br />ASSESSMENT <br />CLEANUP <br />CORRECTIVE ACTION <br />WATER QUALITY (WDR) <br />2950 <br />2953 <br />2960/3526/3527 <br />2965 <br />2959 <br />2854 <br />FACILITY FILE: COMPLETE BUSINESS / SITE/ PROJECT INFORMATION: <br />IS THIS ANEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No IN <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES No ❑ <br />BUSINEaWFACILITY/SITE/PRomwNAME,r.YM", p`ikk� .}.on 04A ��� <br />APN: �Q$ `�b v <br />SITE ADDRESS / PROJECT LOCATION { �, O o H % t `! (-� ('fin �k'� <br />1 V Y `I rel. <br />BUSINESS PHONE A t <br />,v� <br />Om L' rAfO <br />` <br />STAT IF 9 5 330 <br />BOARD OF SUPERVISOR DIBMIOT LOOATION CODE KEY1 <br />KEY2 <br />MAILING ADDRESS, IF DIFFERENT FROM FAwLITY ADDRESS kaoo Concord a00 <br />MAtuNGADDRESS CITY Cu rw-a r4 <br />STATE//��zip Q �5�o <br />`.il <br />SIC CODE COMMENT. - <br />THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IIS7 DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />BUSINESS NAME V C �+ /1 ��°SOG�,^-T� - iqc . ATTENTION: OROARE OF (OP"0AfA0 E R�vs� <br />MAILING ADDRESS /� O J lE �O'i -33 � �T PHONE ri `,6) / V 7 7 147, <br />CITY os5 �L/1 C. E STATE G ZIP <br />� { <br />' ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLIN&T <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, <br />or Responsible Party and I acknowledge that all PERM[T FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated <br />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 <br />provided on this application is true and correct; and that all regulated activities will 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 soonasit is available and at the same time it is <br />ss}provided to we or r rese atl <br />APPLICANTNAME (PLEASE PRINT) kS'P�P-NK Pfp (QtJ /►t /� SIGNATURE (- k <br />TITLE /',., ,� TAX ID # - 3 C F _ r- <br />9-3-2015 <br />Site Mitigation MFR 29- <br />�vfZ <br />12FLA JE:D�c-v OR��u-fin! G - <br />p ri L R� <br />9 /-V ID <br />