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SAN J0,-...tUIN COUNTY ENVIRONMENTAL HEALTH C. ARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 5/9 I r-4. 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 />PHONE <br />-4 i -- 6 15 FIRST MI LAST <br />BUSINESS NAME, . <br />ME-C1S-T,A.g., Ca.? <br />E-MAIL ADDRESS <br />,,,,) T,„ 1-' N (c:' vil 42..4( rs-ia e-cc-p cowl <br />OWNER HOME ADDRESS ATTENTION: ORCARE OF (OPTIONAL) <br />Crry STATE Zr <br />OWNER MAILING ADDRESS -1. 61- 0 Woci.11 <br />MAILING ADDRESS CITY <br />1./..CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 GOVERNMENT AGENCY 0 RESPONSIBLE PARTY 0 OTHER <br />X ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />• EHD LOCAL VOLUNTARY <br />CLEANUP <br />2953 <br />RWQCB LEAD - RWQCB LEAD - DTSC LEAD <br />2959 CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />• FED EPA LEAD <br />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 SLL <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES 0 <br />No 0 <br />NOSE1 <br />BuswEss/FACILITY/SiTEIPROJECT NAME sh„Lorcvl c2.3, \ Di..., \ A.c.i.v.c,kc,,k APN:c7.),) z l c, 0 Lb <br />SITE ADDRESS/ PROJECT LOCA BUSINESS PHONE A) A <br />Coy SE ,.. IA_ \ ser z,„ic 7_, <br />Scum OF SUPERVISOR DISTRICT LOCATION CODE KErl i KE12 <br />MAIUNG ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS <br />SikAkIZ P(% o...,)Ar-d- (iNeot)O.C- <br />MAiUNO ADDRESS CITY STATE ZIP <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 ATTENTION: ORCARE OF (OPTIONAL) <br />MAILING ADDRESS . <br />to <br />PHONE , _S-R= 3433 -3 <br />CITY am-z. STATE <br />C- A L7c(1 <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: <br /> <br />OWN ERD <br /> <br />FACILITY/BUSINESSO <br /> <br />THIRD PARTY BILLINQS. <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 />APPLICANT NAME (PLEASE PRINT) TkiL C Ackv vis) SIGNATURE <br />TITLE <br />6.):carst_o-c4 <br /> <br />TAX ID # - <br /> <br />FA #: OWNER ID #: 2:2_,sz iy. ACCOUNT #: J1:j <br />ASSIGNED TO: <br />#: --, PR #: <br />ijk0S-41- / CI q-- I <br />ACCOUNTING COMPLETED BY: DATE: 6/2747 <br />9-3-2015 <br />Site Mitigation MFR 29-