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BUSINESS NAME <br />MAILING ADDRESS-5 k. <br />Ce,y, 5 <br />5t 5-tt_ 3co Ott <br />ATTENTION: ORCARE OF (OPTIONAL) pi k tecci <br />PHONE 3 2_ is— <br />Cm <br />0-v\ Fro-v-624,-(-0 STATE <br />ZIP <br />I ACCOUNT ADDRESS To SEND FEES AND CHARGES: <br /> <br />OWNERO <br /> <br />FACILITY/BUSINESSE <br />THIRD PARTY BILLINGO <br />SAN JP QUIN COUNTY ENVIRONMENTAL HEALTH ^F.PARTMENT <br />SITE MITI _ ,TION MASTER FILE RECORD INFG. ,JATION FORM <br />"MFR"- GREEN FORM <br />DATE SI C /1 7- SHADED AREAS FOR END USE <br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH END <br />PROPERTY C <br />OWNER NAME <br />crro s _et rt t, fit /qt.( kf cc v PHONE <br />67 6 cl- 38 1 6"- l'/o g 1 FIRST MI LAST <br />BUSINESS NAME ISM .51:. ka1110 7 <br />E-MAIL ADDRESS <br />OWNER HOME ADDRESS ATTENTION: ORCARE OF (0P770NAL) <br />CITY STATE ZIP <br />,-- OWNER MAILING ADDRESS 7/(0 t Cot f ti 42 • Or.\1.. <br />MAILING ADDRESS CITY <br />0').1 6-e r ilciz ci Al 0 <br />STATE c ZIP 47 2 41 a g _. 3c7( <br />IY1 CORPORATION INDIVIDUAL <br />PARTNERSHIP <br />GOVERNMENT AGENCY U RESPONSIBLE PARTY <br /> <br />11 OTHER <br />TIA ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />MI EHD LOCAL VOLUNTARY . RWQCB LEAD - g RWQCB LEAD - <br />WATER QUALITY (WDR) <br />2965 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <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 0 No (ik <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES Z NO 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME6/0 5 r p...14 ,-, (we, m on4, c...i..., R a. 4 c 4 APN: t c.c.._ 5 2 0 , 2 1 <br />SITE ADDRESS/ PROJECT LOCATION A‘i <br />sb O k ps,o...,„.,,c„.a e-) t BUSINESS PHONE <br />,acci - `i 66- (33-C <br />CM 5t C k C t- e-y \ STATE ZIP CI caos__ 604 <br />BOARD OF SUPERVISOR DISTRICT I 1,. LOCATION CODE KEY1 Kea <br />MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />SIC CODE COMMENT: <br />I <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 eyntier, Opertsfor, Authorized Agent, <br />or lierps attsible-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 niyjpresentative. <br />APPLICANT NAME (PLEASE PRINT) R : L (L. <br />C7-e 0 foi <br />SIGNATURE <br />TITLE TAx,.. -A <br />FA #: i <br />f-Aoc)2-22/.26— <br />OWNER ID #: <br />DIVO0 207)-0 <br />ACCOUNT #: A <br />A ROD 5L-7--0 Ltz-/- <br />ASSIGNED TO: <br />PR #: <br />?nD541g-q(1 <br />ACCOUNTING COMPLETED BY: 4,(9 DATE: 46/7 <br />9-3-2015 <br />Site Mitigation MFR 29-