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/42,01 Aciy,1%) <br />MAILING ADDRESS 303 4— S.t. Atarr7creme <br />CRY C <br /> <br />FIVV‘064.*•.4.40 <br /> STATE c * <br />ATTENTION gic ci <br />ZIP 40,,s7 <br />AV* sieleoc1 "lejuirstoo," <br />PHONE ffra ell rp8 <br />BUSINESS NAME <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORIVReeetto <br />"MFR"- GREEN FORM <br />DATE if 1 I 4% 12,0 rg iftr, „I4 S F .0711,0 USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: <br />/8 <br />CHECK /F OWNER fricalr.rm EHD <br />PROPERTY <br />OWNER NAME <br />I " ; R.E. pi 4 Ke r c 4 PHONE 9 Oc? .3 6N - yoig' / FIRST MI . LAST <br />NAME 6 i o 5 F. BUSINESS N Agt . itoo-7 E-MAILADDRESS <br />OWNER HOME ADDRESS ATTENTION: ORCARE OF (OPTIONAL) <br />CITY STATE ZIP <br />OWNER MAILING ADDRESS Vtie0 . cez r Ail i a. .0( . <br />MAILING ADDRESS CITY $ladyt toe (Aonict skim. STATE eh ZIP 9 z ye 8 <br />-11.CORPORATION <br /> ID INDIVIDUAL <br /> 1:1 PARTNERSHIP <br /> CI GOVERNMENT AGENCY 1:1 RESPONSIBLE PARTY <br /> CI OTHER <br />'ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />II EHD LOCAL VOLUNTARY .R. RWQCB LEAD - <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />-altWQCB LEAD - <br />WATER QUALITY (WDR) <br />2965 <br />CLEANUP <br />2953 <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? <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? <br />YES CI NO V% <br />YES a No CI <br />BusiNEss/FAciurasmErpRomar NAME 6 1,)5 F ka .` favA( APN /cc / .. yo 2. f <br />SITE ADORESS / PROJECT LOCATION Igo I 0 1 4441D.4 $t • BuipasifHoNifitee) <br />CRY <br />< tee, PtePVN e <br />STATE eA.z° cis-zar <br />BOARD OF SUPERVISOR DISTRICT I / I LOCATION CODE I I Keri I 1 Ker2 I <br />MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />SIC CODE COMMENT: <br />REQUESTOR'S INFORMATION: <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNERD FACILITY/BUSINESS': REQUESTOR0 <br />13ILLING AND COMPLIANCE ACKNONALEDGNIEN I.: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, <br />or Responsible Parry 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 DEP !LENIENT as soon as it is available and at the same time it is provid to me or my representative. <br />APPLICANT NAME (PLEASE PRINT) SIGNATURE <br /> <br />TITLE <br /> <br />Sego /a .'st <br /> T AX ID # <br />FA*: <br />0 0 1:2A 1,5- OWNER ID #: Ov. I Onz,-)eit.o I ACCOUNT*: apt) L4710444 <br />_ <br />ASSIGNED TO: <br />PR #: 0 -cci t %..et 4 ACCOUNTING COMPLETED SY: DATE: <br />SR TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br />Work Plan <br />2903 <br />2904 <br />523 <br />523 <br />545600 <br />$760.00 T, SSA. Urtt L-( <br />Site Mitigation MFR 2-26-2018