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SAN lUIN COUNTY ENVIRONMENTAL HEALIT4LIIU D <br />SITE MITIGATION MASTER FILE RECORD INFORMATIpN FORM <br />"MFR"- GREEN FORM DEC 0 2017 <br />DATE II til ( I / 1,, IN, vi izt IN \iv \ rti, 1 1 r ffiq AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PAM INFORMATION: DEP Midi X 1:614:4 'is CURRENTLY ON PILE WTTN END <br />PRoveare <br />OWNER NAMIE <br />frtlaey g cit/t at el-- PHONE <br />FIRST MI LAST <br />Mamas NAME <br />- E-MAIL ADORES!' <br />OWNER HOME ADDRESS 14 s 3 0 . /A,/, j ,t g..? 74- si-. ATTENTION: ORCARE OF (conouto <br />CiTy <br />5"tec.-v,'‘ STATE 6,4 ZIP q),...• ix; 1 <br />OWNER MAILING ADDRESS SSE,Pti.- <br />MAIUNG ADDRESS CITY STATE ZIP <br />0 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 GOVERNMENT AGENCY 0 REsPoNstaLE PARTY 0 OTHER I <br />X ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />0 EHD LOCAL VOLUNTARY <br />CLEANUP <br />2953 <br />III RWQCB LEAD - II RWQCB LEAD - <br />CORRECTIVE ACTION <br />2960/352613527 <br />WATER QUALITY (WDR) <br />2965 <br />II DTSC LEAD NI 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 NI, No 0 <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES 0 No zr <br />BUSINESINFACIUTY/SITEPROJECT NAME <br /> era, //q rf 5-(> APN: (2.3-1//-0/ <br />SITE MOMS /PROJECT LOCATION i ?, 14 6,(47p1 fr <br />Ca -R. I Ve( <br />BUSINESS PHONE <br />CRY STATEel zip 5f -.0 <br />Gis—z. 6,4 <br />BOARD OP SUPERVISOR Darrocr I I LOCATION Coos I I KEY/ T 1 KEr2 <br />MAILING ADORER., IF DIFFERENT FROM FACILITY ADDRESS <br />MAIUNG ADDRESS WY STATE ZIP <br />SIC Com [COMMENT: <br />THIRD PARTY BILLING INFO: COMPLETE IF NG PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. B LU <br />BUSINESS NAME 03. V..... A c_dry‘s v <br />1 <br />ATTENTION: oftCARE Of (OPITOAMO () Z ecil-, ( <br />'t., <br />MAIUNG ADDRESS gl I g 0 . 5-wed-.... A ve. , 1 <br />P"°"' (6 2,)57 2.-713e <br />Crry e toria. stxreA z_ ZIP 65-3s„./ <br />II ACCOUNT ADDRESS TO SEND FEES AND cHARGEs: OWNERO FACIUTY/BUSINESS 0 THIRD PARTY BILUNG% <br />BILLING AND COMPLI ‘NCE 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 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 COlt NT ENVIRONMENTAL <br />HEALTH DEPARTNIENT as soon as it is available and at the same time it is provided to me or my,eprttve. <br />APPUCANT MANE (KEAN PRINT) ( 7 cc, I&G SicokruitE <br />TITLE Pro:21,-+- <br /> <br />TAX IDS <br /> <br />- <br />FA II: p-A 00A,_1.37 .7 OWNER 10 tow002_2_,73, I ACCOUNT S: Api)014D::1 ASSIGNED TO: <br />nt Tey) 5-4) 2_42_1 ACCOUNTING COMPLETED BY: <br />fe) <br />DATE: 1.21ty <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECKS RECD BY DATE SERVICE REQUE Si INVOICES <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456 00 <br />5760.00 <br />-1, c-6, ;.,4/1:f ‘ 7 p <br />I 2/13 - cc 7 ss i' c( r <br />Site Mitigation MFR 29- XXX 8-1-2017