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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE oc`l 05 ZolV" <br />SHADED AREAS FOR END USE <br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH END ra <br />PROPERTY <br />OWNER NAME <br />D..) go 4 5E r..) PHONE <br />2 " 0 9 '-' 4 ioN -S-78-o FIRST MI LAST <br />BUSINESS NAME <br />E-MAIL ADDRESS <br />OWNER HOME ADDRESS I 1 9,30 S. <br />ATTENTION: ORA (OPTIONAL) C.1 A CRE OF <br />-a 4 ll AC. a5t br-N Un l 'o rl g d . 0 <br />crry r" A „/ <br />STATE Cit ZIP 9s 3 3 5 <br />OWNER MAILING ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />CI CORPORATION <br /> <br />I=1 INDIVIDUAL <br /> <br />LI PARTNERSHIP I=1 GOVERNMENT AGENCY <br /> RESPONSIBLE PARTY <br /> <br />E OTHER <br />''ZI- RWQCB LEAD - <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />RWQCB LEAD - ENVIRONMENTAL END LOCAL VOLUNTARY DTSC LEAD FED EPA LEAD <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />WATER QUALITY (WDR) <br />2965 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 WORK? <br />YES 1=I NoA_ <br />YES)gc No 1=1 <br /> <br />BUSINESS/FACILITY/SITE/PROJECT NAME <br />rr 11 As AA ii'55)‘,:)" 31- CI AE, <br /> <br />APN <br /> <br />SITE ADDRESS! PROJECT LOCATION C 15. ck--1-attiQr <br />BUSINESS PHONE <br /> <br />CITY STATE ZIP <br />5 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEy1 KEy2 <br />MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS <br /> <br />MAILING ADDRESS CITY <br /> STATE ZIP <br />SIC CODE <br /> COMMENT: <br /> <br />'S INFoRMATIoN: <br />BUSINESS NAME <br />01 <br />ATTENTION <br />JJ'A AG/10 G•Lo SA e ; f 0 At-NU-% -11- c. ) 1..".c.... • <br />_ <br />J El )4 ." <br />MAILING ADDRESS F3 -7 w• St‘q <br />PHONE <br />CITY <br />S I Q(,Ic i m "1 <br />-t STA or ZIP -),... <br />-3--- <br />EMAIL ---- AKIvgeo zil•-•• <br />OWNERD FACILITYIBUSINESSD REQUESTORO <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 me or my representative. <br />APPLICANT NAME (PLEASE PRINT) ) El SIGNATURE - <br />PIL);E-t, r A <br />OWNER ID!!: <br />60 . 0 <br />ACCOUNT #: A ASSIGNED TO: <br />ACCOUNTING COMPLETED BY: DATE: en <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUE # INVOICE!! <br />Work Plan <br />2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 '2-.1 i 1 1 1-- -'11- 1 )14 I A.-1,-‘)-11 ‘'ice i 4; <br />I ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br />TITLE Tax ID# <br />Site Mitigation MFR 2-26-2018