Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE November 3, 2016 SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH END <br />PROPERTY <br />OWNER NAME <br />PHONE 209-480-4663 <br />FIRST MI LAST <br />BUSINESS NAME FJJC Investments, Inc. E-MAIL ADDRESS <br />1 i sthuyjucii c-@aol rom <br />OWNER HOME ADDRESS PO Box 635 ATTENTION: OR CARE OF (09770NAL) <br />Judi van Riet <br />CIW Ripon STATE CA ZIP 95366 <br />OWNER MAILING ADDRESS Same as above <br />MAILING ADDRESS CITY STATE ZIP <br />6 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP El GOVERNMENT AGENCY 0 RESPONSIBLE PARTY 0 OTHER <br />ENVIRONMENTAL M EHD LOCAL VOLUNTARY RWQCB LEAD - RWQCB LEAD - <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />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? <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? <br />YES 0 No XX <br />YES 0 No Ea <br />BUSINESS/FACILITY/SITE/PROJECT NAME DeBoer Trucking Am 259 -35-013 <br />SITE ADDRESS / PROJECT LOCATION 201 W. 5th Street BUSINESS PHONE <br />CITY Ripon STATE CA ZIP 95366 <br />BOARD OF SUPERVISOR DISTRICT 1 1 LOCATION CODE 1 kerl I [ KEy2 1 <br />MAILING ADDRESS, W DIFFERENT FROM FACILITY ADDRESS Same as above <br />MAILING ADDRESS CITY STATE ZJP <br />SIC CODE COMMENT: <br />THIRD PARTY BILLING INFO COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />BUSINESS NAME <br />ATTENTION: OR CARE OF (OPTIONAL) <br />MAILING ADDRESS <br />PHONE <br />Cny <br />STATE <br /> <br />ZIP <br />I ACCOUNT ADDRESS To SEND FEES AND CHARGES: <br /> <br />OWNER! <br /> <br />FACILITY/EUSINESSE <br /> <br />THIRD PARTY BILLINGO <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 />Freda Green, Doug Camara, <br />APPLICANT NAME (PLEASE PRINT) Judi van Riet, Charlotte Wright <br /> <br />Tmx Property Owners <br /> <br />tudo# Lk4,-0.4,44e <br /> <br />1-Anif> 7 `/-5 <br />FA #: „....-ASSIGNED to tti ACCOUNT OWNER10 : t. ./I <br />Akooq 3'1.51- <br />TO <br />PR I: <br />-PgDS-q-H3 ( AccouNTING COMPLETED BY: 0 OAT <br />*v....a., <br />SIGNATURE J4 IV/ van 'Riet freda cree1,1 <br />9-3-2015 <br />Site Mitigation MFR 29-