Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
PHONE (./ IQ ) U MAILING ADDRESS C.-- <br />7 SC .9 <br />STATE <br /> ZIP CrrY <br />Fcc)C -To -NI' <br />BUSINESS NAME A <br />/t11pL 1/4'.13 (-CVO v n.ot <br />ATTENTION: ORAleaFjOPTIONAL) r^ <br />) \ ) <br />SAN sA,AQUIN COUNTY ENVIRONMENTAL HEALTH — _PARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 00 S I 07 C. 1 -1 <br />SHADED AREAS FOR EHD USE <br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD ry <br />PROPERTY <br />OWNER NAME <br />PHONE <br />(2- C(%) LI '‘<, ''' 3 5 5 y FIRST MI LAST <br />BUSINESS NAME <br />CLi'F.Ai-i a Pt "TeN,A i< L s ,)E__S <br />ETII:t7R)E113Srl <br />OWNER HOME ADDRESS , '1 / <br />. '‘.3 <br />ATTENTION: OR CARE OF (OPTIONAL) <br />CITY <br />C L1C. (4 -is P" Cr <br />STATE ZIP <br />OWNER MAILING ADDRESS 'I 1' <br />/ <br />MAILING ADDRESS CITY I , 1 i <br />, / STATE I , ZIP I 1 <br />ORPORATION <br /> 0 INDIVIDUAL <br /> 0 PARTNERSHIP <br /> 0 GOVERNMENT AGENCY <br /> 0 RESPONSIBLE PARTY <br /> 0 OTHER <br />LEAD - <br />CO RECTIVE ACTION <br />RWQCB LEAD - <br />.TER QUALITY (WDR) <br />II ENVIRONMENTAL II EHD LOCAL VOLUNTARYtSczRWQCB III DTSC LEAD In FED EPA LEAD <br />ASSESSMENT CLEANUP 2959 2954 <br />2950 2953 2960/3526/3527 2965 <br />ORMATION° <br />/ <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES 0 No X <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? / YES X No 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME p p <br />PIG-)F1 ,-- Po E —5 c,-. o F--l- 0 (,apoc. APN: 1 -7 s ,, i 2. n <br />-• <br />f...) 3 <br />SITE ADDRESS / PROJECT LOCATION <br /> y ) u- .0. OD s -I, . BUSINESS PHONE <br />CITY j STATE ZIP I 5 <br />c." <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE Kul , KEY2 <br />MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS / <br />MAILING ADDRESS CTIY 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 />NT: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, <br />or Responsible Party and I acknowledge th t all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated <br />with this project will be billed to me at th address identified above as the ACCOUNT ADDRESS for this site. I also certify that all information <br />provided on this application is true and orrect; 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 j available and at the same time it is provided to me or my representative. <br />VV. <br />I ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNERD FACILITYIBUSINESSD THIRD PARTY BILLING, <br /> <br />BILLING AND COMPLIANCE ACKNOWLEDG <br />TITLE <br />ievn---1-, 7 CS..) Eitok APPLICANT NAME (PLEASE PRINT) <br />P N &AA AGA' <br />SIGNATURE 104189 <br /> <br />TAx ID# <br /> <br />FA #: OWNER ID #: ACCOUNT #: ASSIGNED TO: <br />PR #: ACCOUNTING COMPLETED BY: DATE: <br />9-3-2015 <br />Site Mitigation MFR 29-