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BUSINESS NAME A44Aiv...2.11 2.nowA60,‘to4 ) <br />MAILING ADDRESS a.p; — ) <br />5 PrAi o <br />CITY <br />Si4 c\t —h„..i <br />ATTENTION: ORCARE OF (OPTIONAL) CI <br />7AN (4r) 1. <br />PHONE <br />STATEcA ZIP <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE -ç5 — Z0 1g" SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD Or <br />PROPERTY <br />OWNER NAME <br />3 9 /3 /si "Yowdeli PHONE <br />LAST <br /> <br />FIRST MI <br />BUSINESS NAME A vi:or 1) T ruc-KituvA-7 E-MAIL ADDRESS <br />OWNER HOME ADDRESS <br />1 (3 0 -14.• e V SA41 'C'• ) ON-- . ATTENTION: ORCARE OF (OPTIONAL) qo Jo A A V410 E )) <br />CITY STATE <br />BFAttl;it Clet <br />ZIP q 95,0 <br />OWNER MAILING ADDRESS <br />SA AiNt. PO A; o v e. <br />MAILING ADDRESS CITY 5 STATE ZIP 4 MC M A bo v t <br />El CORPORATION ..;i0NDIVIDUAL <br /> <br />12 PARTNERSHIP U GOVERNMENT AGENCY <br /> <br />0 RESPONSIBLE PARTY <br /> <br />0 OTHER <br />A ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />• EHD LOCAL VOLUNTARY <br />CLEANUP <br />2953 <br />RWQCB LEAD - RWQCB LEAD - <br />DTSC LEAD <br />2959 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />• FED EPA LEAD <br />2954 <br />FACILITY FILE: COMPLETE BUSINESS! SITE/ PROJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? <br />YES D No igt <br />YES>: No 1=I <br />BUSINESS/FACILITY/SITE/PROJECT NAME y 4 NDA•ti "Tr4L-k At W ,IS" <br />APN: i y 2.. , zxil <br />SITE ADDRESS / PROJECT LOCATION <br />lon -2-- N gADA-DAJA-1 Ayr- . BUSINESS PHONE <br />CITY <br />5 --0 c4 Tel ,../CPT - 0 5 STATE ZIP <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE Kerl KEY2 <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 PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />1 ACCOUNT ADDRESS To SEND FEES AND CHARGES: <br />OWNERD <br /> <br />FACILITY/BUSINESSD <br /> <br />THIRD PARTY BILLING <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 <br />information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all <br />applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the <br />undersigned Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby <br />authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY <br />ENVIRONMENTAL 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) )1 141N E)) kr- SIGNATURE AAA" <br />TITLE <br />Pc? IMPs eilAt <br /> <br />TAX ID # <br /> <br />FA #: P4602-4166 <br />OWNER ID MO ajoej.23c,44 ACCOUNT #: Aps.60 ,74.....c- 6 7 ASSIGNED TO: <br />PR #: ?gos_425-z7 /1 ACCOUNTING COMPLETED BY: <br />,0 <br />DATE: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$990700 <br />$650.00 (45-‘, .2..ii (71-. , 0 5 v0015113 <br />9-3-2015Site Mitigation MFR 29- XXX 6-2-2017