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SAN Jk UIN COUNTY ENVIRONMENTAL HEALTH ARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 2,1 1.0 / 1 B SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD <br />PROPERTY <br />OWNER NAME <br />.— — PHONE <br />(S- s 0) 2-L, - .S FIRST MI Lcsr <br />„ . - BUSINESS NAME A E-MAIL ADDRESS <br />/-11 I M Ir‘I "Vctv‘s avvi miext Tirtkck-S A ta o p/Sivirbi tiel <br />OWNER HOME ADDRESS 7 .3 0 r4c _i_ c...,,L4c,e,÷e4.. 1_0AI ATTENTION: ORCARE OF (OPTIONAL) <br />CITY Sf 0 (...,L4.0 u. STATE cilv ZJP Ci 52_0(4.7 <br />OWNER MAILING ADDRESS <br />C‘AAA,P 1,4- S ijJ 4.7 e-' <br />MAILING ADDRESS CITY STATE ZIP <br />0 CORPORATION <br />0 INDIVIDUAL <br /> 0 PARTNERSHIP 0 GOVERNMENT AGENCY 0 RESPONSIBLE PARTY 0 OTHER <br />ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />in EHD LOCAL VOLUNTARY MI RWQCB LEAD- M RWQCB LEAD- <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />DISC LEAD . FED EPA LEAD <br />2959 2954 <br />FACILITY FILE: COMPLETE BUSINESS! SITE/ PROJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES A. <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES 0 <br />NO 0 <br />No„,.14 <br />BUSINESWACILITY/SITE/PROJECT NAME r •-• <br />.1 d Eii-S+ CA 6k-Kt-e- W 0, <br />ppm t (01- - t 3 -c..) 3, <br />) C, -i" -189 -c)-3 1-uy "./ <br />SITE ADDRESS / PROJECT LOCATION /"L <br />1 3 av,v-1---e--r wo.).7 <br /> <br />SP.BUSINES I4ONE _ c <br />Crry STATE ZIP <br />BOARD OF SUPERVISOR DISTRICT I LOCATION CODE I I Kerl 1 Ker2 I <br />MAILING ADDRESS IF DIFFERENT FROM FACILITY ADDRESS , ........-- <br />MAILING ADDRESS CITY STATE ZiP <br />SIC CODE COMMENT: <br />THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPEFtlY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />BUSINESS NAME av.9 1,, <br /> <br />ATTENTION: ORCARE OF (OPTIONAL) <br />MAILING ADDRESS r_e.„4„. 13 ( L/A <br /> PHONE <br />CITY ,..-- <br />t r ret. Vt• <br />STATE • ZIP C,A s-c) i <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER[] FAciLITY/BuSINESSEL THIRD PARTY BILLING 0 <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) 7\ \ SIGNATURE <br />15" <br />TnIE TAX ICI* <br />FA #: FACZ4,4 /4/J <br />OWNER ID #: TV)01,-)a3r)37 ACCOUNT IP: 74 R <br />2 <br />c:‘,434. <br />ASSIGNED TO: <br />PR # <br />DATE: ACCOUNTING COMPLETED BY: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECKII RECIPD BY DATE <br />, <br />SERVICE REQUEST# INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 "/ i 1 q sY5:-. 00 <br />Site Mitigation MFR 29- XXX 8-1-2017