Laserfiche WebLink
SAN JOA—iN COUNTY ENVIRONMENTAL HEALTH DE r ...(TMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 17 January 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 & Levand Paula Levand - Trustee PHONE <br />(661)904-2133 <br />Bright Family Tkiit MI Joan Konkel - Trtgtee <br />BUSINESS NAME Levand Bright Property <br />E-MAIL ADDRESS <br />OWNER HOME ADDRESS ATTENTION: ORCARE OF (OPHON4L) 24692 Sand Wedge Lane <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 />El INDIVIDUAL <br /> <br />El PARTNERSHIP <br /> <br />El GOVERNMENT AGENCY <br /> <br />XI RESPONSIBLE PARTY <br /> <br />OTHER <br />ENVIRONMENTAL EHD LOCAL VOLUNTARY MI 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 />M 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 El No s <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES X No 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME Levand Bright Property <br />(1 <br />APN 233-36-18 <br />SITE ADDRESS / PROJECT LOCATION 3 East 11th Street BUSINESS PHONE <br />CITY Tracy STATE CA ZIP 95376 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEy2 <br />MAILING ADDRESS , IF DIFFERENT FROM FACIUTY ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />SIC CODE COMMENT: <br />RECIUESTOR'S INFORMATION: <br /> <br />BUSINESS NAME Advanced GeoEnvironmental <br /> <br />ATTENTION Rene Toth <br /> <br />MAILING ADDRESS 837 Shaw Road <br /> <br />PHONE (209)467-1006 <br /> <br />CITY Stockton <br /> <br />STATE CA ZIP 95215 EMAIL Rtoth©advgeoenv.com <br /> <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: <br /> OWNERO <br /> <br />FACILITY/BUSINESS:I <br /> <br />REQUESTORlii <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 p epresentative. <br />APPLICANT NAME (PLEASE PRINT) Rene Toth SIGNATURE <br />TITLE Staff Geologist <br /> TAX ID <br />FA #: FA 6„,...24. , OWNER ID #: (5 w0 02 2_,Z ACCOUNT 0: A.A.,..Do 167 2...... ASSIGNED TO: <br />PR #: <br />.5-4./-1 8 1 7 ACCOUNTING COMPLETED BY: DATE: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE SERVICE REQUEST# INVOICE# <br />2903 <br />2904 <br />523 <br />523 Work Plan iC(0 <br />$456.00 <br />$760.00 1,S3t• S Vql‘k g'15 elM 1,c <br />• <br />Site Mitigation MFR 2-26-2018