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SHADED AREAS FOR EHD USE DATE <br /> <br />TA. ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />0 EHD LOCAL VOLUNTARY <br />CLEANUP <br />2953 <br />I=1 RWOCB LEAD - <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />RWOCEI LEAD- <br />WATER QUAUTY (WDR) <br />2965 <br />DTSC LEAD <br />2959 <br />0 FED EPA LEAD <br />2954 <br />0 CORPORATION <br /> <br />0 INDIVIDUAL 0 PARTNERSHIP <br /> <br />0 GOVERNMENT AGENCY IRRESPONSIBLE PARTY D OTHER <br />BUSINESS NAME k_v„, ev\xti , e sc <br />MAILING ADDRESS F.T"--( TZ, vey-e„, GI <br />ATTENTION: ORCARE OF (OPTIONAL) <br />PHONE (i()) 4P -1 0 t1 <br />CITY STATLE„A <br /> <br />cpsDL <br /> <br />SAN a .JIN COUNTY ENVIRONMENTAL HEALTH L ARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTL VON PILE WITH END <br />PROPERTY PHONE <br />I 0) 2.3a (0 5-13 1 O N NIUAEr LA ST <br />BUSINESS NAME <br />fii <br /> m oald 1-$1( R.th—C Aviv Dig rAWA qeAl <br />.116_01", E-MAIL ADDRESS <br />OWNER HOME Aoonse ATTENTION: ORCARE OF (OPTIONAL) -."() EA S. + LA-/ <br />Cirv STATE CA ZIP CICi7-0(.0 <br />OWNER MAILING ADDRESS s e__ <br />ZIP MAILING ADDRESS CITY STATE <br />FACILITY FILE: COMPLETE BUSINESS! SITE/ PROJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES )21, No o <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES 0 NO Tti, <br />BUSINESS/FACILITY/BM/PROJECT NAME 9 7, 0 i.: ci 54_ u APN: k (0- _ y!..)--- _- <br />SITE ADDRESS I PROJECT LOCATION 5 ( <br />7 , , 10 a...icli, —ST.511 BusliEsipso <br />-- <br />ir <br />,.._ <br />Crrv STATE ZIP <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE fKsvi f KEV2 I <br />MAILING ADDRESS ,W DIFFERENT FROM FACIUTY ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />SIC CODE COMMENT: <br />THIRD PARTY BILLING INFO: COMPLETE IF BILUNG PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNERO FACILITY/BUSINESS O THIRD PARTY BiLLINDEI <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 OVIRGES 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 S <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 ENAIRONMENTAt <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) tj ai-t, C.-1y (& t) SIGNATURE <br />TITLE <br />c c-k <br /> TAX ID* <br />FA B: OWNER ID!: 1 ACCOUNTS ASSIGNE0 TO: <br />PR 0: ACCOUNTING COMPLETED BY: DATE: <br />SR TYPE PE sc FEE INFO ANT REMITTED CHECKS RECYD BY DATE SERVICE REQUESTS INVOICES <br />w ork Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 — <br />Site Mitigation MFR 29- XXX 8-1-2017