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tA APPLICANT NAME (PLEASE PRINT) S • ro-ti SIGNATURE
<br />TITLE St4C-f- Co-eA+:)
<br />FA St: OWNER ID #: ,")/4/00 2.24 (..)/
<br />ACCOUNTING COMPLETED BY:
<br />ACCOUNT #: 4/6n,71,4476 3---- ASSIGNED TO:
<br />DATE: -7
<br />cal 100
<br />PR If: A0541 g
<br />TAX ID.
<br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECENED
<br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM JUN 15 20'
<br />"MFR"- GREEN FORM
<br />DATE c -3 I- t i 1
<br />Tyfl W-6*-AuftsE
<br />IT/SE1V10ES
<br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH END a
<br />OWNER NAME
<br />PROPERTY PHONE
<br />% 1'V7 4 1 1 FIRST MI LA ST
<br />BUSINESS NAME L 0 141)'+1,Lt
<br />....
<br />f, et S ,opLi . .;•.- , .
<br />E-MAIL ADDRESS I ,
<br />0 A Atij e. cc, Kir ly 7 .(0.,
<br />OWNER HOME ADDRESS S S3 1 I I (1( * . ‘,, „
<br />VC1(1 ATTENTION: OR CARE OF (OPTIONAL)
<br />CITY ot , Cr te. V... STATE , ) ZIP C/L1 ft L
<br />OWNER MAILING ADDRESS cil k., i T4e,c ., u.,i iil f7_,t ' ,
<br />MAILING ADDRESS CITY lift I .1 _ rir n . I STATE , 1 ZIP Cit./ A 1.
<br />0 CORPORATION
<br /> D INDIVIDUAL
<br /> El PARTNERSHIP
<br />
<br />0 GOVERNMENT AGENCY VIRESPONSIBLE PARTY
<br />
<br />OTHER
<br />[p ENVIRONMENTAL
<br />ASSESSMENT
<br />2950
<br />I. EHD LOCAL VOLUNTARY RWQCB LEAD - RWQCB LEAD -
<br />CLEANUP
<br />2953
<br />CORRECTIVE ACTION
<br />2960/3526/3527
<br />WATER QUALITY (WDR)
<br />2965
<br />DISC 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 El
<br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES ID No 0
<br />BUSINESS/FACILITY/SITE/PROJECT NAME -is 1 c ( 0,,, , ( bib 13144, 1 CV4(efil )
<br />APN: 1 1,5 _. bz,v _I
<br />SITE ADDRESS / PROJECT LOCATION 2,c,9 is- •"'
<br />(f„ll (14) r_t 1 41 .
<br />BUSINESS PHONE
<br />CITY S4VC. H-•-,
<br />STATE 1- -, LP
<br />BOARD OF SUPERVISOR DISTRICT 11 LOCATION CODE i 1 KEY1 , KEY2
<br />MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS
<br />MAILING 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 ‘ \.. _f",..1 ATTENTION: ORCARE OF (OPTIONAL)
<br />MAILING ADDRESS c(3•7 K t i 0,.,‘!",..4,AV Aft 1-1` All '
<br />(PHONE -1 i ,t Elio 03 si.,
<br />Cm (5A /44 P‘ir* , CA STATE C ZIP 90 iI Z (
<br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER0 FACILITY/BUSINESSO THIRD PARTY BILLINGE3
<br />BILLING AND COMPLLANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I ant 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 ACCOLNT 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 />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE#
<br />Work Plan 2903
<br />2904
<br />I 523 $417.00
<br />525 $695.00
<br />9-3-2015Site Mitigation MFR 29- XXX 10-26-2015
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