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CITY Lo4t STATE c ZIP <br />OWNER MAILING ADDRESS <br /> <br />*Mum ADDREas Cny STATE ZIP <br />THIRD PARTY BILLING INFO: COMPLETE IF BILLJNO PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />BUSINESS WISE ArrernoN: CARE OF (O11SSN4L) <br />MAILING Am:4mm PHONE <br />CITY STATE ZIP <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT juN 3 2017 <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM ENVIRONMENT <br />DATE 0 i 2.---1 i I SAM USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK END F OSPIER IS Cumemonrcw Paz wmv <br />OWNER NAME <br />PROPERTY <br /> (2 04) (y) 0:23 -- 9 1+ FiRST MT LAST <br />fluelNE8""E A -1. Sa LiN) CLA mc,for 10 i_ • <br />EMAIL Aooftess <br />ArnumoN: CARE Of (OPHONAL) OWNER HOME <br />ADDRESS 59 No v-Ek _LI4:fAup_2A Lie, <br />El CORPORATION ImonnouAL 0 PARTNEIDNIIP 0 Clow/omen AoeEcr y„RESPONSISLE PARTY <br /> <br />AsNVTRONMENTAL <br />SESSMENT <br />2950 <br /> <br />El END LOCAL VOLUNTARY <br />CLEANUP <br />2953 <br />RWQCB LEAD - <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />RWQCB LEAD - <br />WATER QUALITY (WDR) <br />2965 <br />DTSC LEAD <br />2959 <br />El FED EPA LEAD <br />2954 <br /> <br />FACILITY FILE: COMPLETE BUSINESS / SITE/ PROJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION HOT PREVIOUSLY REGULATED BY THE ENviRoNNENTAL NEACIN DEPARTMENT? <br />IS THIS AN METING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? <br />YES )5t No 0 <br />YES 0 No ;X <br />BusimEsulFAcarry/Brry./PRox-cor Hum A _ 1 <br />S- 60..d 0•AA. A I\A u lt-O'r ---k,' .e..-- , <br />APN: <br />SITE ADDRESS / PROJECT LOCATION BUSINESS <br />LI No r-t-t-, CAIA-4. A,.)2,_ PHONE <br />cnv a, STATE <br />L-7- LA 0 <br />Boo OF SUPERVISOR Ovrnacr TION I <br />NAMING ADDRESS , IF DIFFERENT FROM FACIUTY ADDRF-Se ,--- <br />', Cs_APA,. e.-- <br />'AAIUN° ADORESS CITY STATE ZIP <br />SIC Cooe • <br />FACILITY/BUSINESS:I <br /> <br />THIRD PARTY BILLINGEI <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 ACCOITNT 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 provided to me or my representative. <br />APPUCANT Mum (PLeme PRINT) t\,) 6..+1,,,vc.„..," \ ,A,e,ovuovN SIGNATURE -v <br />TM-E 5 (A 2 ykv\f 41 ivvl,41 <br />TAX 10111 <br />G.AA C.11fr <br />FA t e:02-Lt / OWNER ID S: Atkr)274 ACCOUNT*: A2co‘i-V-8"1 /4S-il ASSIGNED TO: <br />PRt 2 o ACCOUNTING COMPLETED BY: / 4 I <br />SR TYPE PE <br />. . <br />Sc FEE INFO ANT REMITTED <br />-,r-- <br />CHECK# RECVD BY DATE SERVICE REQUESTO INVOICE# <br />W ork Plan 2903 <br />2904 <br />523 <br />523 <br />$390.00 <br />$650.00 <br />9-3-2015Site Mitigation MFR 29- XXX 6-2-2017 <br />I ACCOUNT ADDRESS To SEND FEES AND CHARGES: OVVNER4