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n ENVIRONMENTAL ASSESSMENT 2950 EHD LOCAL VOLUNTARY CLEANUP 2953 LI RWQCB LEAD- CORRECTIVE ACTION 2960/3526/3527 RWQCB LEAD- WATER QUALITY (WDR) 2965 DTSC LEAD 2959 FED EPA LEAD 2954 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION MASTER FILE RECORD INFORMATION FORM "MFR"- GREEN FORM DATE 1 2) ' 2'2, -232 SHADED AREAS FOR EHD USE OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS cuRRavnroN FEE WITH EHD PROPERTY OWNER NAME PHONE LI (5 - 9 -1tt - i75o. ,FIRST MI LAST BUSINESS NAME E., - ,2 0 ,ye ii t, Lyol. R- ‘,.,..J , , in je. -if t EISAIL ADDRESS OWNER HOME ADDRESS ATTENTION: ORCARE OF (OPROANL) CITY STATE ZIP OWNER MAILING ADDRESS '1,3 Li 5 S . 3----t-k; c. AVC .. 1 STATE --1-6 MAIUNG ADDRESS CITY SD 5 C. -- ZIP 5; TS 0 1 D CORPORATION ,INDIVIDUAL 0 PARTNERSHIP D GOVERNMENT AGENCY D RESPONSIBLE PARTY . OTHER FACILITY FILE: COMPLETE BUSINESS! SITE/ PROJECT INFORMATION: Is THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? IS THIS AN DUSTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES' No 1:1 YES D No VS BUSINESS/FACILITY/SITE/PROJECT NAME ill k SOL-31-1/4 Cher.Dkee Looe.... APN 0 6 2 _ 0 6 0 _ ix So SITE ADDRESS / PROJECT LOCATIONI./ 2. i -.., SelLn+k GI efeke e Laile. BUSINESS PHONE CITY L CV. I) , STATE ( ,") ZIP 75 2 610 BOARD OF SUPERVISOR DISTRICT 1 ! LOCATION CODE Keil 1 Ker2 11 MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS MAILING ADDRESS CITY STATE ZIP SIC CODE COMMENT: REQUESTOR S INFORMATION: BUSINESS NAME L1/4) ek i (As _ A .1,506 osie ATTENTION ,/vt f To‘ii 1 0 r MAILING ADDRESS "2-)0 50 skok6\va• PHONE Cr - rS12 - 7) Li STATE ZIP CI CiTY e_1" c)cs. cr-f,nees.+0 EMAIL VKAAL410 re Wadkrt I ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNERO FACILITY/BUSINESS REQUESTORV 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 ACCOUIVT 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 representative. APPUCANT NAME (PLEASE PRINT) (.412 .11 SIGNATURE Gire_ 0,) FA #: FA0026453 °VIN" I": 0W0025100 ACCOUNT NI: AR0050318 ASSIGNED TO: PR N: PR0546616 ACCOUNTING COMPLETED BY: DATE: SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan 2903 2904 523 523 Ci456:0-0 456 CC JW 3/26/2021 SR0083485 $760.00 Confirmation Number 122780292 Site Mitigation MFR 2-26-2018 TITLE TAX ID #