|
ZIP STATE Vq//0 Crry t, 6i
<br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNERD FACILITY/BUSINESSEI THIRD PARTY BILLINGE
<br />6,0 7, /fr,
<br />2-56, c;ok- 2o°
<br />ATTENTION: ORCARE OF (OPTIONAL) J
<br />(Av., '
<br />PHONE 22 2 _, y206
<br />BUSINESS NAME
<br />.5
<br />--77,7e,
<br />-
<br />MAILING MAILING ADDRESS
<br />SAN ‘. .QUIN COUNTY ENVIRONMENTAL HEALTH
<br /> CEIVED
<br />SITE MITIGATION MASTER FILE RECORD INFORMATION WW2
<br />"MFR"- GREEN FORM 9 .2V.
<br />DATE --/2---‘7/, 7 ENVIRONVEMLIftsffR EHD USE
<br />OWNER FILE:
<br />PERM 1 /SEFiyrgS
<br />PARTY INFORMATION: CHECK IF OWNER IS CURREN rrLE WITH EHD COMPLETE(P-ROPERTY OWNER/ RESPONSIBLE
<br />PROPERTY
<br />OWNER NAME
<br /> /h,„--- PHONE
<br />/ 204 , 5 - S Z 36' / FIRST MI LAST
<br />BUSINESS NAME E-MAIL ADDRESS
<br />OWNER HOME ADDRESS /0E3'3 ::Iiiye..4.--C, pc, 114 ,c'ctel
<br />ATTENTION: ORCARE OF (OPTIONAL)
<br />Orr ./.,_ I,- 1 _ STATE (.,-1)1 ZIP 67.5 z is
<br />OWNER MAILING ADDRESS 4,
<br />g"X 535 ..)
<br />MAILING ADDRESS CITY 5/pc_ K ,,..\ STATE c ji/ ZIP e?
<br />0 CORPORATION
<br />
<br />II INDIVIDUAL El PARTNERSHIP
<br /> El GOVERNMENT AGENCY El RESPONSIBLE PARTY
<br />
<br />El OTHER
<br />MI ENVIRONMENTAL III EHD LOCAL VOLUNTARY II RWQCB LEAD - rE RWQCB LEAD -
<br />WATER QUALITY (WDR)
<br />2965
<br />ASSESSMENT
<br />2950
<br />CLEANUP
<br />2953
<br />CORRECTIVE ACTION
<br />2960/3526/3527
<br />111 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? YES 0 No E
<br />Is TI-US AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES IS No 0
<br />BUSINESS/FACILITY/SITE/PROJECT NAME
<br />14-,r - pprey >6.,i4 lir. L/ 5/e,<_._ 7,,-._ /- APN: /Os - //c) - o6
<br />SITE ADDRESS / PROJECT LOCATION 7
<br />/0 4/ BUSINESS PHONE
<br />CITY CT_ _ - , . ,k-.... c• I I
<br />STATE/4 ZIP c.i- ,-3 -2 ! s
<br />BOARD OF SUPERVISOR DISTRICT I LOCATION CODE KEY1 KEy2 1
<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 />BILLING AND CONIPLIANCE ACKNOWLEDGNIENT: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent,
<br />or Responsible Par0 , 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 m r prese tative. z ---
<br />
<br />APPLICANT NAME (PLEASE PRINT) (1."'t SIGNATURE
<br />
<br />5h. 0' /0 / :S
<br />TAXID# TITLE
<br />/0t„,--
<br />FA #: r-4 OD ..:2,,, F ; OWNER ID #: 91/4W / 73/7 ACCOUNT #:_i4kz632j7.03-5---
<br />-
<br />ASSIGNED TO:
<br />PR #: piens-,..3 7-7 -7 1 ACCOUNTING COMPLETED BY: le DATE:
<br />_
<br />DATE SR TYPE
<br />Work Plan
<br />PE
<br />
<br />Sc
<br />2903 523
<br />2904 -525-
<br />FEE INFO
<br />$417.00
<br />$695.00
<br />AMT REMITTED CHECK# RECVD BY SERVICE REQ1JEST# INVOICE#
<br />5 23
<br />9-3-2015Site Mitigation MFR 29- XXX 10-26-2015
|