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SAN ... lUIN COUNTY ENVIRONMENTAL HEALTH ARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />SEP 2 1 2017 <br />ENVIRONMENTAL HEALTH <br />DATE 9 / ? '-' / 7 <br />_ ........... mn..013 <br />SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WTH EHD <br />OWNER NAME <br />PROPERTY <br />61 ( IA I 01/4- frliVi- Na---1 -,1_4. 6, Li CLAr c_ PHONE <br />94 85 6 / - tifAS" FIRST <br />1 MI LAST <br />I A.- E-MAIL ADDRESS BUSINESS NAME ., <br />. <br />i / <br />I I .. <br />OWNER HOME ADDRESS 3 DO ,,,, ole. ia. ATTENTION: ORCARn, op ogid , <br />CITY Ahrl'al <br />7 <br />Ylit di,dc STATE cc) ZIP ? 5 - 4 6 c) <br />OWNER MAILING ADORE S a 5 a-C. ô"- <br />MAILING ADDRESS CITY STATE ZIP <br />0 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP V...-OVERNMENT AGENCY 0 RESPONSIBLE PARTY E OTHER -, <br />M ENVIRONMENTAL • EHD LOCAL VOLUNTARY <br />CLEANUP <br />2953 <br />EIRWQCB LEAD - <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />RWQCB LEAD- DTSC LEAD <br />2959 ASSESSMENT <br />2950 <br />WATER QUALITY (WDR) <br />2965 <br />MI . FED EPA LEAD <br />2954 <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 Er- <br />i S THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES E NO 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME APN: i 77_ -ic, 0 ,_ <br />SITg‘ADDRESS / PRQJECT LOCATM <br />- 02.22, e,-.•-ri-lr, 'fcIkr gar \iktk, <br />BUSINERS PHRIF,_ <br />7.-C) 7 .... 7 x 5- c4,343 <br />ory (--, f L. ( _ _ L-rt <br />STAe4 ZIP CI C 2.06 ...._ <br />OCA) A <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE 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 g ey.-td, (wig 4.(eci vt_c ATTENTION: OXI,E...0FAcIP770NAL) <br />Icesoure-eS <br /> <br />... ' <br />MAILING ADDRESS i 3s---/ LAjot, )4...1r. PHONEç 631 _ Oggei <br />STATE ck ZIP „goo s <br /> <br />Orr Ve.44.41) VCA-- <br /> <br />- ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br /> <br />OWNERO <br /> <br />FACIUTY/BUSINESSO <br /> <br />THIRD PARTY <br />BILLING 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 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 DEPARTMENT as soon as it is available and at the same time it is provided to me or my re resentativ <br />R P/eV APPLICANT NAME (PLEASE PRINT) SIGNATURE <br />TITLE Fro) 44 Mewet6-e4r <br /> <br />TAX ID # „‘ <br />) <br /> <br />FA* OVVNER ID #: ACCOUNT #: ASSIGNED TO: <br />PR #: ACCOUNTING COMPLETED BY: DATE: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 <br />Site Mitigation MFR 29- XXX 8-1-2017