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IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTPAENT? YES pi No 0 <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES Li No <br />SITE ADDRESS! PROJECT LOCATION <br />BUSINESS/FACILITY/SITE/PROJECT NAME 9 7.)o -EA 5 +- u3 6u--1 <br />(A A'-- <br />APN: t L 1— — UT)--- 0 3 <br />suswEsspHow <br />( 5-10) .2_(C,2 —1 <br />STATE ZIP <br />BUSINESS NAME etAilvIr'-e}r‘ v\sq co•-\_CA ATTENTION: ORCARE OF (OPTIONAL) <br />PH43NE(,-Tio) q(D-iool MAILING ADDRESS LI Kire,,_ b•-•, IJC) <br />TITLE <br />SAN Jo, AN COUNTY ENVIRONMENTAL HEALTH D. .RTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE "Z_ / i LI /.1(5 SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH END <br />PROPERTY <br />OWNER NAME <br />. - — — PHONE <br />C 5: 0) 2-Ca (0 - .53 I i TRST Mi LAST <br />BUSINESS NAME 1) i vl 1 U cctA 4, av 0 <br /> <br />tk a_c A viv D icv,,,avvkl ew- E-MAIL ADDRESS <br />OWNER HOME ADDRESS / '''' 0 E.......4 < 4- Cia.Ad+R....1 LA3 el ATTENTION: ORCARE OF (OPTIONAL) <br />CITY rD to 6_1 v.k. STATE <br />OWNER MAILING ADDRESS < ce, e..... <br />MAILING ADDRESS CITY STATE ZIP <br />1:1 CORPORATION <br /> 12 INDIVIDUAL <br /> <br />0 PARTNERSHIP <br /> <br />0 GOVERNMENT AGENCY a RESPONSIBLE PARTY <br /> <br />0 OTHER <br />la ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />• END LOCAL VOLUNTARY <br />CLEANUP <br />2953 <br />RWQCB LEAD- RWQCB LEAD- <br />DTSC LEAD <br />2959 <br />FED EPA LEAD <br />2954 CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2985 <br />M • <br />FACILITY FILE: COMPLETE BUSINESS / SITE/ PROJECT INFORMATION: <br />BOARD OF SUPERVISOR DISTRICT ' I LOCATION CODE I 0 Keil I KEy2 . <br />MAILING ADDRESS • IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS Om STATE zp <br />SIC CODE <br /> COMMENT: <br />THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />Crry T o C - sc,. STAJ:E.A. <br /> <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNERO FACILiTY/BUSINESSO, THIRD PARTY BILLING0 <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 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 COUNTY ENVIRONMENTAL <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) I c- ) SIGNATURE <br />TAX ID # <br />PAL OWNER ID #: ACCOUNT #: ' ASSIGNED TO: <br />PR S: ACCOUNTING COMPLETED BY: DATE: <br />SR TYPE PE SC FEE INFO MAT REMITTED CHECK# RECYD BY DATE SERVICE REQUEST# INVOICE# <br />Work Plan <br />2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 <br />Site Mitigation MFR 29- XXX 8-1-2017