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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DErARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 01/I 74 2-o1 --• SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD 14 <br />PROPERTY <br />OWNER NAME <br />PHONE <br />Z. 05 •- C19 3 — 7 777 FIRST MI LAST <br />BUSINESS NAME A PRopErm'E.3 <br />c/ <br />/ c) &N B Lo.vp E-MAIL ADDRESS <br />6 LoM e DMA SO/)i4- f • Cer^•-• <br />ATTENTION: ORCARE OF (OPTIONAL) OWNER HOME ADDRESS <br />c A,/ . '57 kJ . 14 42E1 A-or\ E. <br />CITY STATE cifl ZIP 9 C 2...0 1 <br />5 1 oc, tc. -r o l../ Ci's <br />OWNER MAILING ADDRESS t 1 <br />I. 'I <br />MAILING ADDRESS CITY I , <br />I % I STATE , , ZIP • • <br />KCORPORATION <br /> D INDIVIDUAL <br /> Li PARTNERSHIP <br /> <br />GOVERNMENT AGENCY D RESPONSIBLE PARTY <br /> CI OTHER <br />.R.RWQCB LEAD- <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />ENVIRONMENTAL EHD LOCAL VOLUNTARY RWQCB LEAD- 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? YES 0 No R. <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES No <br />BUSINESS/FACILITY/SITE/PROJECT NAME Si Erri, La;Ef (CASE ek. I 0 APN y7- / ao 3p <br />SITE ADDRESS! PROJECT LOCATION <br />3 7 j kJ./ • <br />BUSINESS PHONE 1-\-co-crt-c.r A•it-Z. . 1/4/ 3- 7 777 <br />Crry STATE ZIP CAA-o <br />BOARD OF SUPERVISOR DISTRICT <br />- . <br />LOCATION CODE Keel Kea <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 A, 1 <br />r' 9ILVA IN-C-E 0 to 1.N v ../" on 0,\L"+":4. ) I- "4- . ATTENTION '71-..: 0.1 t) )oti .r- <br />MAILING ADDRESS g- .57 <br />.5-}1^,A, <br />I <br />A o • be 0 <br />PHONE ) Yo -.) - roo V <br />CITY 5 7 c.i -1 sc To ., STATE <br />CA <br />ZIP 9 5 LI r EMAIL ."----- <br />1 CQ Z )/JINct4 AIN qZ° Zd <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 />I <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNERD <br /> <br />FACILITY/BUSINESSD REQUESTORIST\ <br />APPLICANT NAME (PLEASE PRINT) I ;pi) 43 Cv E.)% <br />A pju_r MA NrA Cr <br />SIGNATURE -7fA414/5 <br />TAX ID # TITLE <br />544f) <br />OWNER ID #:alodOD v 0,1/4.3 ACCOUNT #: Akbetisr--3 ASSIGNED TO: <br />PR!!: 3...c..4.1e9ng- =MIMED 1:111=11..111111 DATE: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D HY DATE SERVICE REQUEST# INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 ' 1 't ',- i" / k .i si [ 41 1 q so-007'H <br />Site Mitigation MFR 2-26-2018