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DATE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: <br />PROPERTY — <br />OWNER NAME -FFrif LAS r <br />SHADED AREAS FOR EHD USE <br />-1-/R (4-c ALA-to DicrAckv\i-les( <br />OWNER MolISE ADDRESS (3) c, GO C.-1 <br />CrrT r) <br />E-MAIL ADDRESS <br />STATE Cfi, ZIP 615 Z-0 (49. <br />CHECK IF OWNER IS CURRENT( Y OIV FILE WITH EHD <br />PHONE <br />Cr510Y .2-(a 0 .5-23 <br />ATTENTION: ORCARE OF (OPTIONAL) <br />0 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 GOVERNMENT AGENCY D OTHER RESPONSIBLE PARTY <br />FACILITY FILE: COMPLETE BUSINESS / SITE/ PROJECT INFORMATION: <br />DTSC LEAD <br />2959 <br />El FED EPA LEAD <br />2954 <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? <br />Is THIS AN EXISTING PROJECT LOCATION, RUT A NEW SCOPE OF WORN? <br />Busii4E8S/FACILITY/SrTE/PROJECT NAME <br />YES pi No 0 <br /> <br />YEs 0 No 4 <br /> <br />APN: I tUr-isoi T2: 0 LA c.)4.-- <br />Tit ENVIRONMENTAL <br />ASSESSMENT <br />El EHD LOCAL VOLUNTARY <br />CLEANUP <br />RWQCB LEAD- <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />O RWQCB LEAD - <br />WATER QUALITY (WDR) <br />2965 2950 2953 <br />MAILING ADDRESS 7 7.) I", GI 011 PHI3NE (S-.10) q1 1-) <br />STAIIEzpi ZIP io 5 1.) <br />BUSINESS NAME Tos.:4,. ev\iti <br />co„.4.-A ATTENTION: ORCARE OF (OPTIONAL) <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: <br /> <br />OWNERO <br /> <br />FACILITY/BUSINESSO, THIRD PARTY BILLINCO <br />SAN Jc JIN COUNTY ENVIRONMENTAL HEALTH L 1RTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />OWNER MAILING ADDRESS ‹- Ck...vv\ e__ <br /> <br />MAILING ADDRESS CITY STATE 2a. <br /> <br />SITE ADDRESS I PROJECT LOCATION Busirseli, E <br />CrTY STATE ZJP <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE I Kefl <br />I MAILING ADDRESS ,IF DIFFERENT FROM FACILITY ADDRESS <br />1 MAILING ADDRESS CITY 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 />BILLING AND COMPLIANCE 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 Hot'RIA CHARGES associated <br />yvith this project will be billed to me at the address identified above as the Accouvr 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 FEDERAI. 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 FN N IRONMEN I AL <br />HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />APPLICANT NAME (PLEASE PRINT) c y-L..) <br /> <br />SIGNATURE <br /> <br />TITLE f,co. <br /> <br />TAX ID I <br /> <br />FAD: OWNER WM I ACCOUNT*: ASSIGNED TO: <br />PR I: <br />L. <br />ACCOUNTING COMPLETED BY: DATE: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK% RECVD BY DATE SERVICE REQUEST% <br />'1 <br />INVOICE/ . <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 _ <br />Site Mitigation MFR 29- XXX 8-1-2017