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0 PARTNERSHIP 0 GOVERNMENT AGENCY OTHER 0 REsfoNsisLE PARTY 0 INDIVIDUAL 0 CORPORATION
<br />FED EPA LEAD
<br />2954
<br />o RWQCB LEAD - I
<br />;1E( DTSC LEAD WATER QUALITY (WDR} 2959 2965
<br />0413 LOCAL VOLUNTARY
<br />CLEANUP
<br />2953
<br />RWQCB LEAD
<br />CORRECTIVE AcrioN
<br />2950/352513527
<br />El ENVIRONMENTAL
<br />ASSESSMENT
<br />2950
<br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT
<br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM
<br />"MFR"- GREEN FORM •
<br />RECE11VIED
<br />JAN 12 2018
<br />CAT! 1 44.0 i
<br />i
<br />SHADEMEATI4A9MI
<br />i
<br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: GIIECM if OwNER a Comma. r I:went nrrn END fl
<br />PROPERTY
<br />OwNea HAW
<br />1.7„ -,,...71- col r , i Cc. ..-A ,^^,.: •,, ' 4 - ,.) PHONE
<br />9 25- 3q.3 - 21 2 -2- .. F1RSr A41 tA.Ir
<br />BustmEss NAM —r- v,.. -./- < , , ,. 1 6.-j A, .._, .„ . 4, e j E4UJL AGGRESS ,
<br />/VI S. ; II, e•C? i n tejr.)e,..,,,.,..A
<br />OwNER HOME ADDRESS / r 3 z c -4-,- ) As 0, - ,-- <- ATTENTION' maul OF (turncoat)
<br />Crry STATE ('A ZIP 9 6
<br />°warn MAILima Aocaeps (C 2 2 C, , 4-, . 1 (-
<br />"LULING ADORERS Cm Tracy STATE CA ZiP 95376
<br />FACILITY FILE: COMPLETE BUSINESS / BITE/ PROJECT INFORMATION:
<br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES* No 0
<br />Is THIS AN EXISTING PROJECT LOCATION. BUT A NEW SCoPE Of WORK? YES 0 No X
<br />BustNE33/FAcaurr/SirE/Pitcuect Num I r• r 0 p• ("sc ./1 7---,,, c 1 1-I; Ili- Eleole-,,,-4-4,ej S-c I ao t APN: 253-030-14
<br />SITE ADDRESS / PROJECT LocATioN 21660 SOUTH CORRAL HOLLOW ROAD BUSINESS PHONE
<br />Crry TRAcy STATE ZIP 95377
<br />BOARD OF SUPERVISOR Clumucr I 1 °' °° I K KEY2 jr-
<br />MAILINO ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS 72 / 9 z 4, - 5 r e r . ,, 7. t‘ .- ( / r , c,
<br />MasUNG ADDRESS Crry STATE ( r e c 7 A P 6 5 ..? -7- 7
<br />1 mc CoOE COMNIENT:
<br />THIRD PARTY BILLING INKo: COMPLETE IF BILUNG PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTYIDENTIRED,A8OVE.
<br />BUSINESS NAME WALLACE-KUHL LE ASSOCIATES ATTENTION: ORCARE Of (0,770NAL)
<br />116 41
<br />MAILING ADDRESS 3050 INDUSTRIAL BOULEVARD PHONE 9164724434
<br />CDT WEST SACRAMENTO STATE CA ZIP 95691
<br />I1 ACCOUNT ADDRESS To BEND FEES AND CHARGES: OWNER 0 FACILTTY/BUSINESSO THIRD PARTY BILIJNA
<br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent,
<br />or Responsible Parry and I acknowledge that all PERAIIT 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 ACCOUN'TADDRESS 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 COUNTY ENVIRONMENTAL
<br />HEALTII DEPARTMENT as soon ask is available and at t same time it is provided to me or my re sentative.
<br />7;4 - ApPUCANT NAME (PLEASE PRINT) ja..0015 611. I es SIGNATURE
<br />TAX 101 TITLE
<br />FA 0: i_L—_-400.2.„hi4,/, .....13 S: 01,000.23y I ACCOU NT t Afe_octs--601 ASSIGNED TO:
<br />PR I: —
<br />/5/-°f‘ - S ,?1,5-1 7
<br />AccOuNTINa COMPLETED sr 4/ S Dare
<br />SR TYPE TYPE PE sc -FEE INFO
<br /><
<br />AMT REMITTED CHECK% RECVD BY DATE SERVICE REQUEST' INVOICEll
<br />Work Plan 2903
<br />2904
<br />523
<br />525
<br />ti)( 4417:00'
<br />$695.00 e. 4 01-1,1 v--- v..,0-0 ,7 ,6' s/03
<br />9-3-2015Site Mitigation MFR 29- XXX 10-26-2015
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