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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENPECE/Vg, T --
<br />SITE MITIGATION MASTER FILE RECORD INFORMATION FOIRM
<br />"MFR"-GREEN FORM 4 ti 9
<br />DATE BA3 /1 ei
<br />... r"IVIRry,,, _
<br />b p OMPAREAAREAS FOR EHD USE
<br />r-
<br />r-r,141
<br />OWNER FILE: COMPLETE PROPERTY-OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNEH IS CURRENTLY ON F7LE WITH EH D
<br />PROPERTY
<br />-ElymeBNABB
<br />CAnD;r1A-k 1P3tk i•Cr4CA PHONE
<br />( g56) S 97 1 ' - °I 100
<br />FIRST AV ST
<br />BUSINESS NAME 0 tri bred. 91 TiyivrIcs _ DT E-MAIL E-MAIL ADDRESS
<br />O.( 1E)jrt0., IOU f -0YOk ect -c)-k-s,
<br />OWNER HOME ADDRESS 1 15 ....A cAs ti Qi,.\.... ATTENTION: ORCARE OF (OPPONAL)
<br />CITY 1\si'‘ STATE c L.... ZIP
<br />OWNER MAILING ADDRESS - 30LYYle._ -
<br />MAIUNG ADDRESS CITY STATE Z/P
<br />CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 GOVERNMENT AGENCY 0 RESPONSIBLE PARTY 0 OTHER
<br />ENVIRONMENTAL II EHD LOCAL VOLUNTARY RWQCB LEAD - RWQCB LEAD - X DTSC LEAD
<br />2959
<br />ASSESSMENT
<br />2950
<br />CLEANUP
<br />2953
<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 Nor PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES El No X
<br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES 0 No E
<br />BUSINESSIFACILITY/SITEIPROJECT NAME
<br />leArtAA DATAVVIl‘ GS - D1S i 4).A.4 D'S
<br />APN
<br />_ SITE ADDRESS / PROJECT LOCATION ,--5,),:lal co,vmfai $r),4 RS . BUSINESS PHONE1850 . ail ....frl i 01
<br />CITY TycAc5 STATE CA ZIP 01 5 6 Y) _
<br />BbAkoo0StikkvisoR DISTRICT 1 ' , ' LodAyKiN CODE ,,' KEYI , K -
<br />MAIUNG ADDRESS, IF DIFFERENT FROM FACILITY ADDRESS t-trior-6 S4...
<br />MAIUNG ADDRESS CITY
<br />W . Wz) STATE P Lf
<br />jP (2-5-1 S.
<br />SIC CODE ,,-. . : . , • poMME:NT: -
<br />REOUESTOR'S INFORMATION: _
<br />BUSINESS NAME Ojilov, j •..y.‘,1 • vrreC.Nrk ),(\ 1 1V0C - ATTENTION LA,c...4... e...:A-
<br />-
<br />MAILING ADDRESS --1 i --1 b pck.‘'.;)(Asa...e........, ......,\A4.4r....._, \ ,t PHONE
<br />
<br />erre STATE (jac--' ZIPqic,„( EMAIL 1 in.R1 c an ovNie_mo . coy-0
<br />I
<br />ACCOUNT ADDRESS To sEND FEES AND CHARGES: OWNERD FACILITY/BUSINESSLI REQUESTO4N‘' I
<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 pro o m o my representative.
<br />APPLICANT NAME (PLEASE PRINT) L 5N. -44 w\k„1 /41-z4 SIGNATURE
<br />Tine TAX ID*
<br />FA* r OWNER ID #: I . , ACCOUNT* ASSIGNED TO:
<br />PR : ,
<br />'
<br />ACCOUNTING COMPLETED 5Y.: ., I I r .,-
<br />-----,-----
<br />DATE:
<br />SR TYPE * P
<br />
<br />FE AMT REMITTED cHECKg; RECVD BY:7: ERV1C E REQUEST# INVOICE#
<br />2903 Work Plan 2904
<br />523
<br />523
<br />
<br />$760.00,
<br />
<br />Site Mitigation MFR 2-26-2018
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