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BUSINESS NAME A. AvIN ^cep cEP 01•114i. st. twAt" MAILING ADDRESS 1 " 3 ") 5 14,44 .1) Cm( arA.- ATTENTION: OR CARE OF (OPTIONAL) CI Ca 1 PHONE kZA 4 14 4041‘ C%tr)/4 se— -io o le STATE ZIP c SAN J( UIN COUNTY ENVIRONMENTAL HEALTH - r)ARTMENT SITE MITIGATION MASTER FILE RECORD INFORiviATION FORM ±MF11.5.- GREEN FORM DATE )01Iq Z 0) 7 SHADED AREAS FOR EHD USE OWNER FILE: COMP ETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD X PROPERTY OWNER NAME An i..1 L. PHONE (4•311:-/593 '-1 FIRST MI LAST NAME MC.B.i1)1A AiAl ESTA-"CE 7-0N 4 eST AAr" 4" E-MAIL E-MAIL ADDRESS ihl I t rill H-a*6.44;1.Ceee% (OPTIONAL) OWNER HOME ADDRESS ATTENTION: OR CARE OF CITY STATE ZIP OWNER MAILING ADDRESS 1 j 1 r••1 PIP A 04 iv C MAILING ADDRESS CITY SA STATE c pt ZIP f4 3 c) s t 9S) 48- 0 CORPORATION El INDIVIDUAL SPARTNERSHIP 0 GOVERNMENT AGENCY 0 RESPONSIBLE PARTY 0 OTHER IM ENVIRONMENTAL . EHD LOCAL VOLUNTARY . RWQCB LEAD - RWQCB LEAD - WATER QUALITY (WDR) 2965 ASSESSMENT 2950 CLEANUP 2953 CORRECTIVE ACTION 2960/3526/3527 E DTSC LEAD M FED EPA LEAD 2959 2954 FACILITY FILE: COMPLETE BUSINESS / SITE/ PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES 0 No' IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES 7,, No D BUSINESS/FACILITY/SITE/PROJECT NAME m..6;»,•„ (2,:4)'-r4c& 1.04M- APN: 1b7 tsb - 2-) SITE ADDRESS! PROJECT LOCATION El Do rA p 5 /r BUSINESS PHONE 40g 5513 - !lit E ZIP 5Z° BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY') KEY2 MAILING ADDRESS, IF DIFFERENT FROM FACILITY ADDRESS MAILING ADDRESS CITY STATE ZIP SIC CODE COMMENT: THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNERD FACILITY/BUSINESS:I THIRD PARTY BILLIN BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, or Responsible Party and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated 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 provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner, Operator, Authorized Agent, or Responsible Pally for the project located above under facility/site address, I hereby authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representat . e. APPLICANT NAME (PLEASE PRINT) Tie) -A I C4,42114,,--- SIGNATURE Tt,;4•-• PAs St LT ,MANACrt FA #: .,11 -111°9)3731 OWNER ID #: 00602_2_05- ACCOUNT #: ipap#3 77/ ASSIGNED TO: P Ft #: fe.ros_,41 ....7 ACCOUNTING COMPLETED BY: DATE: SR TYPE PE SC FEE INFO AMT REMITTED CHECK# REM BY DATE SERVICE REQUEST# INVOIC E# Work Plan 2903 2904 523 523 $456.00 $760.00 - \ l'''N; -..k.i: Site Mitigation MFR 29- )00( 8-1-2017 TITLE TAX ID #