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Act.° C --e, F,„„„ vitro" 1mm 1,.." 1..c1 a ATTENTION: ORCARE OF (oPrionfm) y r 0 cv2))41- PHONE ST Ea tr._ T o MAILING ADDRESS 1317 .71006) Re•ts.D CITY BUSINESS NAME STATE c ZIP I ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER0 FACILITY/BUSINESSD THIRD PARTY BILLINGX SAI JAQUIN COUNTY ENVIRONMENTAL HEALT, EPARTMENT SITE MITIGATION MASTER FILE RECORD INFORMATION FORM ±MFR5- GREEN FORM DATE 09.' II '-' 2.- I) / ..? SHADED AREAS FOR EHD USE OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLrav FILE WITH EHD PROPERTY OWNER NAME PHONE PHONE ZoR - 1-11.'o -155-4 FiRST M1 LAST BUSINESS NAME EL D • rAND a L-40c, l+s) 1 dWoy_s i_t_c_ E-MAIL ADDRESS -rc..ictlitittanGtozitsboiv- OWNER HOME ADDRESS pgza. gay, lata 1 to ATTENTION: OR CARE OF (OPTIONAL) CITY S T °L i - STATE co4 ZI K -ran R 95201,0 OWNER MAILING ADDRESS P. 0 • &to,. (a o 1 ID MAILING ADDRESS CITY s-ro c...r. T ova STATE ciA ZIP cv 5 za In XPORPORATION INDIVIDUAL D PARTNERSHIP 0 GOVERNMENT AGENCY D RESPONSIBLE PARTY 0 OTHER ENVIRONMENTAL EHD LOCAL VOLUNTARY X RWQcB LEAD - CORRECTIVE ACTION 2960/3526/3527 RWOcB LEAD - ASSESSMENT 2950 CLEANUP 2953 WATER QUALITY (Wm) 2965 DTSC LEAD FED EPA LEAD 2959 2954 FACILITY FILE: COMPLETE BUSINESS! SITE/ PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES 0 No3K YEsX. No 0 j 7s--- I2D-,,2, BUSINESS/FACILITY/SITE/PROJECT NAME 778.4K LIAL N IAL. AFN: 11,5,_.., i t cAL;FoReq 1 A SITE ADDRESS / PROJECT LOCATION 3 it1 S .5. El 490m 0 (.3 sr. BUSINESS PHONE vael - 4 1. Ng — I sc 4 CITY S r ()wit r n 04 CPT- STATE ZIP II 9 z c) 10 BOARD OF SUPERVISOR DISTRICT I I LOCATION CODE I I KErl I I KEY2 I MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS MAILING ADDRESS CITY STATE ZIP SIC CODE COMMENT: THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, or Responsible Party and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated 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 provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my re resentative. 4PAht- TAX ID # FA #: FAcc).224.2.E.t: OWNER ID #: 0 !Aka .22-252_ , I ACCOUNT #: A ky.y+i) 01 ASSIGNED TO: PR 4: ?Ro574-22-Og- ACCOUNTING COMPLETED BY: ,A DATE: V.37) SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE SERVICE REQUEST INVOICE# Work Plan 2903 2904 523 523 $456.00 $760.00 e- , , ---- 67/4,1 ,11--- cvc- 7 1 C I Site Mitigation MFR 29- XXX 8-1-2017 APPLICANT NAME (PLEASE PRINT) -71m IN'rJ j j 0%) PA03 Ecr ANNA, G/ TITLE SIGNATURE