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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEr.aRTMENT SITE MITIGATION MASTER FILE RECORD INFORMATION FORM --7 "MFR"-GREEN FORM DATE 1127=17 Z 7 I / SHADED AREAS FOR EHD USE OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLYON FILE w/TH EHD PROPERTY -" 'a C'k PHONE OWNER NAME FiRST ST 2q-2 - 'C BUSINESS NAME Tract-1 V f e Q L� E-MAIL �L r I OO,co OWNER HOME ADDRESS 12 -7 v er roX P O ad/�� ATTENTION:ORCARE OF(OPTJON o Cm (mss 5; A I a 1 Y1 I`+v$ CA l�/.} D L V STATE ZIP OWNER MAILING ADDRESS MAILING ADDRESS CITY STATE Zip C3.CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER r- _NVIRONMENTAL EHD LOCAL VOLUNTARY ❑ RWQCB LEAD— ❑ RWQCB LEAD— MSSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) ❑ DTSC LEAD ❑FED EPA LEAD 2950 2953 2960/3526/3527 2965 2959 2954 FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OFF{WORK? YES Z NO ❑ BUSINESs/FACILITY/SITE/PROJECT NAME '�-[t C L o ICC' I (� APN. �� SITE ADDRESS I SOJECT LOCATION BUSINESS PHONE n C CITY7rcTATE ZIP BOARD OF SUPERVI80R DISTRICT LOCATION CODE KEY1 KEY2 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 � !4 ec �h VIr �n V I Ce S ATTENTION:ORCARE OF(OPTIONAL) MAILING ADDRESS I Oa,h k II vl --92-00 PHONE /C-�J/ti - /(O CITY ST h 7JP ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,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 PRINT) �, 1_ y SIGNATUR T re,\QCT t/seOIOc; I� TAxID# !ZO — f // f FA/: �00�`��_. OWNER IDA: ACCOUNTa�: /IA8810NE0T0: PR S: l ACCOUNTING COMPLETED BY: DATE: 9-3-2015 Site Mitigation MFR 29-