Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DErmRTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE <br />/ ? — / '7 <br />SHADED AREAS FOR END USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION. ' CHECK IF OWNER IS CURRENTL V' ON FILE WITH END Rr <br />PROPERTY <br />OWNER NAME <br />, eh,/ gir o t 6k_ , -1-04-1 )4a. ' ----i 6 VIA, ( 67 UCLA/ a PHONE <br />9/ -8sq-oms" FiRst A,41 LAsr <br />BUSINESS NAME _ , ipi_. <br /> <br /> <br />(OP <br />rillyz.. i‘i\oace-- OWNER HOME ADDRESS ATTENTION: GROARYOF <br />CITY 410144L )/fIL alas STATE (.._...p ZIP 95-6 6 n <br />OWNER MAILING AocREgS a, <br />MAILING ADDRESS CITY STATE ZIP <br />. - <br />0 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP EIG.OVERNMENT AGENCY 0 RESPONSIBLE PARTY 0 OTHER <br />IN ENVIRONMENTAL 0 EHD LOCAL VOLUNTARY <br />CLEANUP <br />2953 <br />ErRWQCB LEAD— <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />0 RWQCB LEAD - <br />WATER QUALITY (WDR) <br />2965 <br />0 FED EPA LEAD <br />2954 ASSESSMENT <br />2950 <br />II DTSC LEAD <br />2959 <br />FACILITY FILE: COMPLETE BUSINESS / SITE/ PROJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES 0 No Ce- <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES Er- No 1:1 <br />BUSINESS/FACILITY/SITE/PROJECT NAME APN: i 77_ 240 ,_ 0 Ct. <br />SiTADORESS / PR2JECT LOCATION <br />16 <br /> <br />O2-6 Sc.,ti-IA Pr'14To,14 ii.letAg.) <br />BuSINEIS PHANg. <br />CITY S4 <br />-OCJiCAV A <br />ST4 ZIP <br />BOARD OF SUPERVISOR DISTRICT 1 [ LOCATION CODE j KEY1 KEY2 <br />MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS 5 <br />MAILING ADDRESS CITY STATE ZIP <br />SIC CODE COMMENT: <br />THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />BUSINESS NAME nI A\A„ <br />e-At ,Za-vx kt-i,e(v-c . ATTENTION: cARE OF ArTIONAL) ,o r- ic.e.geurce,s Lre, c <br /> <br />MAILING ADDRESS 35-1 LA ..)6,„ p •6/1 <br /> <br />PHONE005- 6 31 _Ogg, ti <br /> <br />STATE ZIP <br />I <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br /> <br />OWNEREi <br /> <br />FACILITYIBUSINESSE <br /> <br />THIRD PARTY BILLINGe-- <br />BILLING AND COMPLIANCE ACKNo‘rt.EDGNIENT: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, <br />or Responsible Party and I acknowledge that all PERMIT 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 ACCOUNT ADDRESS 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 DE PARTNIENT as soon as it is available and at the same time it is provided to me or my r resentativ <br />APPLICANT NAME (PLEASE PRINT) (V--eA/ P/V.0 <br />SIGNATURE <br />TITLE ?v`O' ic4 a6-eAr <br /> <br />TA' 6-46ci g 2-55- Fe-4 <br /> <br />FA #: p...-A. 00 2.2,+2.47 1 OWNER ID #: OW0022.so I ACCOUNT #: /.k.604.572.1 ASSIGNED TO: <br />PR #: Was4l--2-3(1- ACCOUNTING COMPLETED BY: I) DATE:er.ii 17 <br />SR TYPE PE Sc FEE INFO AMT REMITTED . <br />, <br />CHECK# RECV'D BY DATE SERVICE REQ EST INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760,00 1., t ( ' '' L Y 1 /zoo 5 (2--c .,' 1,S' L'i 1 <br />Site Mitigation MFR 29- XXX 8-1-2017