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BUSINESS NAME A <br />if 1U/A "C. t D cto A./ ro +-A I <br />ATTENTION: OR CARE OF (OPTIONAL) <br />PHONE 2 b'S - 414)7-109 ‘• MAILING ADDRESS 17 S INA A . <br />Crry S-r Cv( 'TO .r%1 <br />STATE ZIP <br /> <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: <br /> <br />OWNERD <br /> <br />FACILITY/BUSINESSO <br /> <br />THIRD PARTY BILLING ' <br />SIGNATURE <br />TAX ID# <br />SAN QUIN COUNTY ENVIRONMENTAL HEALTH . _PARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE <br />09 4/ "1- rl) ^ 2'421 -7 SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD N <br />PROPERTY <br />OWNER NAME <br />JOI rtk 4::) I— t <br />PHONE <br />vosi--143-7777 <br />E-MAIL ADDRESS <br />8/0A, I_M As." :1 t . c. a", <br />FIRST MI LAST <br />B BUSINESS NAME <br />5i? ri A Lg. "'fur /"1.4 "iv FAL 'rvitrS <br />OWNER HOME ADDRESS ATTENTION: ORCARE OF (OPTIONAL) <br />CITY STATE ZIP <br />OWNER MAILING ADDRESS <br />i N. C riiniChn 5t . -ilt 3D o . <br />MAILING ADDRESS CITY <br />--TA <br />r STATEFL ZIP / g6 c. <br />El CORPORATION <br /> D INDIVIDUAL 1:1 PARTNERSHIP <br /> <br />GOVERNMENT AGENCY XRESPONSIBLE PARTY <br /> <br />0 OTHER <br />1.1 ENVIRONMENTAL . EHD LOCAL VOLUNTARY ,Igz RWQCB LEAD - <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />RWQCB LEAD- <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />WATER QUALITY (WDR) <br />2965 <br />MI 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 t2c <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF wow? YES A No D <br />BUSINESS/FACILITY/SITE/PROJECT NAME 5 i z rr" LINIIIt r APN: <br />SITE ADDRESS/ PROJECT LOCATION BUSINESS 3115 kki. 11-A2..z)-1-0") Avt . PHONE zo., - cril -7777 <br />CITY S. 7 o CX To n, C Pl- 1 5 Zn3 STATE ZIP <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE Keil Kea <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 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 representative. <br />APPUCANT NAME (PLEASE PRINT) C4 t A.e- <br />50; ICI r`Vi itvA-E• t TITLE <br />FA #: <br />--A0c)23'-06, <br />OWNER ID #: <br />/0 kJ ao 21 (fi(34/ <br />ACCOUNT. <br /> <br /> ife , n ASSIGNED TO: <br />PR St:ACCOUNTING COMPLETED BY: DATE: 047 <br />9-3-2015 <br />Site Mitigation MFR 29-