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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT
<br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM
<br />"MFR"- GREEN FORM
<br />DATE SHADED AREAS FOR EHD USE
<br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD
<br />PKoPurry
<br />OWNER NAME
<br />PHONE
<br />2 o `I - ? S 2- - 40"0 FIRST MI LAST
<br />BUSINESS NAME s - .... r / I. I, Co ,, fv,...,A) : e-/-:.e .s , h L C
<br />E-MAIL ADDRESS
<br />OWNER HOME ADDRESS ATTENTION: ORCARE OF (OPTIONAL)
<br />CITY STATE ZIP
<br />OWNER MAILING ADDRESS / 0 2 i,,, a r, +r , ) ,... ... , v.
<br />MAIUNG ADDRESS CITY 1."-r 4 ( 7 STATE ,,i, 7JP qs- 3 .4 4
<br />N:f CORPORATION 1=1 INDIVIDUAL 0 PARTNERSHIP 0 GOVERNMENT AGENCY [II RESPONSIBLE PARTY I: OTHER
<br />/1K ENVIRONMENTAL E EHD LOCAL VOLUNTARY I. RWQCB LEAD - . RWQCB LEAD -
<br />ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY (WDR)
<br />2950 2953 2960/3526/3527 2965
<br />. DTSC LEAD 1.1 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?
<br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK?
<br />YES TX, No 0
<br />YES El No W
<br />BUSINESS/FACILITY/SITE/PROJECT NAME e,-- /f : ,c co bir 1/•,,C ;,it 1.3
<br />APN 24/ 6 -- /110 - e
<br />SITE ADDRESS / PROJECT LOCATION Pri•I'VX 1/011. rr sy. VA /fp! c..; %AA <AI; u1-1- ..,.. .1-6,
<br />,51 A!'/'j 2gou4cr•IAh/4 ' , 1"a^
<br />"-
<br />,
<br />.6, r..2-2 1
<br />r-c
<br />'7
<br />,
<br />BUSINESSPHONE
<br />,,-c.fr cal. i 14'1 "" f2"
<br />CITY
<br />r '' X- c -7 STATE C,(... ZIP I'S] 7 7
<br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KppyI.gt41 Kea
<br />MAIUNG ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS
<br />RECEIVED
<br />MAIUNG ADDRESS CITY
<br />2a16 8
<br />STATE ZIP
<br />SIC CODE COMMENT: AUG 0
<br />REQUESTOR'S INFORMATION:
<br />. , BUSINESS NAME tx ), // k 1 1 4J3' =4 4
<br />) ALTti sANAct tlE Jo oepARNTmlitm
<br />ENNAKONNIE ATTENTION /1A_A -r Fp-) 7::-7 —
<br />Ll MAILING ADDRESS 3 0 5 -7- ,,,104,--7 PHONE C? /6 (-1?2/
<br />CITY 6.1 ) Cr Aovu". r• STATE {4 ZIP el-3I°"-, EMAIL fy‘ 4 2,70 (1,, ,... ,
<br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES:
<br />OWNER!:
<br />
<br />FACILITY/BUSINESSEI
<br />
<br />REQUESTON
<br />14A
<br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1, the undersigned Applicant, certify that 1 am the Owner, Operator, Authorized Agent,
<br />or Responsible Party and 1 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. 1 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 />APPUCANT NA/AE (PLEASE PRINT) Al (.4 -7 AI ty, /14, - (.4 SIGNATURE ---1,77-7-
<br />
<br />TITLE I ) e
<br />
<br />T"'"
<br />
<br />FA #: .F...4(fx) 7....q, 8 b sr OWNER ID 0: Diduct, 23,446-- ACCOUNT #: lie.004.1...H+ ASSIGNED TO:
<br />PR #:
<br />Ptti)4,3 6A5
<br />ACCOUNTING COMPLETED BY: 4 DATE: g /
<br />/_/)/
<br />1---
<br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# REM BY DATE SERVICE REQUEST# INVOICE#
<br />Work Plan 2903
<br />2904
<br />523
<br />523
<br />$456.00
<br />$760.00 :/b '-i ':'1; .57031 L. ")( sdis-113 se--00-iqct,c )
<br />Site Mitigation MFR 2-26-2018
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