Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 30 July 2019 SHADED AREAS FOR EHD USE <br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD <br />PROPERTY <br />OWNER NAME <br />Levand Family Trust Paula Levand - Trustee PHONE <br />(661) 904-2133 FIRST MI LAST <br />BUSINESS NAME Levand Family Trust Property plevand@mac.com <br />E-MAIL ADDRESS <br />OWNER HOME ADDRESS 24692 Sand Wedge Lane ATTENTION: ORCARE OF (OPTIONAL) <br />CITY Valencia STATE CA ZIP 91355 <br />OWNER MAILING ADDRESS Same as above <br />MAIUNG ADDRESS CITY STATE ZIP <br />0 CORPORATION <br /> <br />0 INDIVIDUAL <br /> <br />0 PARTNERSHIP <br /> <br />0 GOVERNMENT AGENCY IX RESPONSIBLE PARTY <br /> <br />0 OTHER <br />. ENVIRONMENTAL IIII EHD LOCAL VOLUNTARY RWQCB LEAD- <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />M RWQCB LEAD- <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />WATER QUALITY (WDR) <br />2965 <br />. DTSC LEAD M 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 II( <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES EN No 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME Levand Family Trust APN 233-369-14 <br />SITE ADDRESS / PROJECT LOCATION 47 East Eleventh Street BUSINESS PHONE (661) 904-2133 <br />CITY Tracy STATE CA ZIP 95376 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE _ Kerl Kea <br />MAIUNG ADDRESS, IF DIFFERENT FROM FACILITY ADDRESS 24692 Sand Wedge Lane <br />MAILING ADDRESS CT' Valencia STATE <br />CA <br />ZIP 91355 <br />SIC CODE COMMENT: <br />REQUESTOR'S INFORMATION: <br /> <br />BUSINESS NAME Advanced GeoEnvironmental, Inc <br /> <br />ATTENTION Brian Millman <br /> <br />MAILING ADDRESS 837 North Shaw Road <br /> <br />PHONE (800) 511-9300 <br /> <br />CITY Stockton STATE CA ZIP 95215 EMAIL bmillman@advgeoenv.com <br /> <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: <br /> OWNERD <br /> <br />FAC ILITY/BUSINESS REQUESTOREIX <br /> <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 />APPUCANT NAME (PLEASE PRINT) Brian Millman SIGNATURE <br />TITLE Senior Geologist <br /> <br />TAX ID IS <br /> <br />FA #: 0 0 Z.35/ 0 OWNER 10 $: 0 0 Z.... "7_13' a ACCOUNT #: iif 00 ,f3, .3 5 ASSIGNED TO: <br />PR 11: 0 5- 4 I ag f ACCOUNTING COMPLETED BY: DATE: 7 / 11 <br />SR TYPE SC FEE IN AMT REMITTED CHECK# RECVD BY DATE, SERVICE REQUEST# INVOICE# <br />Work Plan 11110 <br />dio <br />i 4 <br />523 <br />523 <br />$456 <br />60.00 16 2 ' (°6 f) 1'0 1 il cko 0 3 01 4 3 <br />Site Mitigation MFR 2-26-2018