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fik/Pf ACE_D Gz 0 =let, <br />?2 5 'AAA" i<oA a <br />ATTENTION: ORCARE OF (OPTIONAL) <br />PHONE <br /> <br />BUSINESS NAME <br />MAILING ADDRESS <br />Crry SIP C \C STATE cpr ZIP 9, dos <br />SAN JuAQUIN COUNTY ENVIRONMENTAL HEALTH 1../mPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHDX <br />PROPERTY <br />OWNER NAME <br />Po N4 Lo K1, G ErS PHONE <br />Qi—y‘a V- 5 76" a FIRST MI LAST <br />BUSINESS NAME T rems-h, )5)I\.S-To A t E-MAIL ADDRESS <br />OWNER HOME ADDRESS A ATTENTION: ORCARE OF (OPTIONAL) 11 q a 0 S'. W I i'ci A . <br />CITY <br />. MA19f 2.t.r; c44- ci S 33 cei STATE ZIP ' <br />OWNER MAILING ADDRESS . ) I i 1 / <br />MAILING ADDRESS CITY STATE 1 , ZIP 1 . 'p 1 / <br />0 CORPORATION <br /> <br />CitINDIVIDUAL <br /> <br />0 PARTNERSHIP 0 GOVERNMENT AGENCY RESPONSIBLE PARTY <br /> <br />0 OTHER <br />ENVIRONMENTAL EHD LOCAL VOLUNTARY Ar RWOCB LEAD — <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />RWQCB LEAD — <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />WATER QUALITY (WoR) <br />2965 <br />DTSC LEAD FED EPA LEAD <br />2959 2954 <br />FACILITY FILE: COMPLETE BUSINESS! SITE/ PROJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? <br />Is THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF Wow? <br />YES 0 No .1..it <br />YES pr, No 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME <br />1'A N N't l' s 5.i o n . sTo A Z APN: i 4 0 „.. cy7 4 ,.. <br />SITE ADDRESS / PROJECT LOCATION <br />S ) 5' tv. C).1/14.r T ‘r v..01 /41 BUSINESS PHONE' <br />Orr S 7 Q c )(TO") . . STATE ZIP 9 5 ao Nizo <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE 1 KEY1 KEY2 <br />MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS <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 />I ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNERD FACILITY/BUSINESSD THIRD PARTY BILLING <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 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 <br />information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all <br />applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the <br />undersigned Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby <br />authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to e or my representative. <br />APPLICANT NAME (PLEASE PRINT) Cv <br />SIGNATURE iffi‘en <br />TITLE TAx ID # <br />FA #: <br />I ,Q 3 r OWNER ID MD thoas- ACCOUNT #: ASSIGNED TO: <br />PR #: <br />Os_27 77 <br />ACCOUNTING COMPLETED BY: DATE: <br />SR TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV.D BY DATE SERVICE REOLIEST# 1 INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$390.00 <br />$650.00 ''.1. • ' t 1 Li by .se-4)0-1,0-is <br />9-3-2015Site Mitigation MFR 29- XXX 6-2-2017