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' L. c (-' ZIP ,a <br />PHONE :57 <br />STATE , <br />/4k <br />THIRD PARTY BILLING': ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNER': FACILITY/BUSINESSO <br />BUSINESS NAME pil_c2z-r I <br /> <br />1 VA t" S\t.:( cc. c e ATTENTION: ORCARE OF (0P770AVIL) Th <br />MAILJNG ADDRESS k- <br />z -2-1. <br />SAN a ..)UIN COUNTY ENVIRONMENTAL HEALTH . _?ARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 7 / .., (-)-.A> I --) SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURREN7LY ON FILE WITH EHD <br />PROPERTY <br />OWNER NAME <br />(---) - 1,- ( I fr..." <br />PHONE <br />3S-- -1S.(4 10 LAST )g FIRST MI <br />BUSINESS NAME Cx.• t ox .' i s %,--‘,S-t-- <br />E-MAII.AOCfE$8 5,, <br />OWNER HOME ADDRESS 1 3 I 4 kAjc., ( s.", t., 4.- ATTENTION: ORCARE OF (0F170NAL) b...,,... (Al i ..g t v 1_45, IA <br />Crre ......r-,403 STATE CAA- sir ei s--3--) G <br />OWNER MAILING ADDRESS . <br />(c5e4. MAILING ADDRESS CITY (A .,_e ct _ c.,_tzr---bv k) sTATE zr <br />ci CORPORATION INDIVIDUAL PARTNERSHIP U GOVERNMENT AGENCY <br /> <br />LI RESPONSIBLE PARTY <br />OTHER <br />cil ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />EHD LOCAL VOLUNTARY RWQCB LEAD- RWQCB LEAD - <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER DUALITY (WDR) <br />2965 <br />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? YESNiZ No CI <br />Is THIS AN COSTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES 0 No N'LK <br />BUSINESS/FACILITY/SITE/PROJECT NAME I, <br />Lkb 6. W 76t* fit 0 / CA i-j cico.---eya MIN: 2-VS-- <br />- <br />SITE ADDRESS / PROJECT LOCATION (2 0 to 4._ it. 0 4 LA...) . t 4., BUSINESS PHONE (-1.04) /SIM <br />6 I <br />CRY _ k — --, LAI/ STATE ZIP <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE I Kerl Kea <br />MAILING ADDRESS, IF DIFFERENT FROM FACILITY ADDRESS 55...et I <br />44 t <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 />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 <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 facffity/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 'ded to me or my representative. <br />APPUCANT NAME (PLFASE PRINT) RV"- e-k-k- b•--( 4. SIGNATURE <br />ThLE <br />C( Sc( e s+ <br />TAx lOt <br />OWNER ID*: FA ASSIGNED TO: ACCOUNT it <br />PR It: DATE: ACCOUNTING COMPLETED BY: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE SERVICE REQUEST# INVOICE# <br />Work 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