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El OTHER ID RESPONSIBLE PARTY El GOVERNMENT AGENCY LI INDIVIDUAL PARTNERSHIP El CORPORATION <br />L kz_ fv) Al PROPERTY <br />OWNER NAME LAST FIRST MI <br />BUSINESS NAME <br />Lis- STATE(A_ ZIP CI <br />1 <br />ZIP STATE <br />ia111) ic3tcs <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: <br />DATE <br />OWNER HOME ADDRESS 3 i„.J P,4 OA, v <br />OWNER MAILING ADDRESS <br />MAILING ADDRESS CITY <br />SHADED AREAS FOR EHD USE <br />CHECK IF OWNER IS CURRENTLY ON FILE WITH END <br />PHONE <br />3 <br />E-MAIL ADDRESS <br />ATTENTION: ORCARE OF (0P770NAL) m <br />BUSINESS NAME v <br />)7 5- IA A MAILING ADDRESS ADDRESS <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEi-ARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />• <br />EHD LOCAL VOLUNTARY <br />CLEANUP <br />2953 <br />):KIRWQCB LEAD - <br />CO RECTIVE ACTION <br />2960/3526/3527 <br />RWQCB LEAD - DTSC LEAD <br />2959 <br />FED EPA LEAD <br />2954 <br />• • • • <br />WATER QUALITY (WDR) <br />2965 <br />rku..n.a I I 1-11=1.. '1.0%11,11-1......., Wa.,•-•••••-v•-• • .......... • ••........-.... .... —. <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES 1:1 No K <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES )Sc NO 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME <br />'n E Il PAO PI. <br />APN i (0 7 e S 0 - 2_) <br />SITE ADDRESS! PROJECT LOCATION <br />.2, 1 1 S E 1 00,0-AP io s =1-- <br />BUSINESS PHONE <br />Cm 5 - 1 <br />STATE:._ ZIP 9 SZ ‘0 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE I Kerl Kea <br />MAILING ADDRESS ,IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />SIC CODE COMMENT: <br />REQUESTOR'S INFORMATION: <br />ATTENTION <br />PHONE <br />EMAIL k ))Ai(-2.,.., A ov ZIP STATE 1/45: <br />FACILITYIBUSINESSD <br /> <br />REQUESTORD <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 provi d tttme or m repr entative. <br />APPLICANT NAME (PLEASE PRINT) M <br />SIGNATURE CA/vve,„0 <br />TAX ID# <br />ASSIGNED TO: <br />FA #: _F.- -A (,), 24 3,-ii OWNER ID #: Z) 202,. ,Z.il_,(1 1 ACCOUNT #: <br />A1'2:Y <br />7 /4, ?if 7 <br />PR #: 'H•- ,_,+3 <br />2_ <br /> <br />- ,(D,4, <br />ACCOUNTING COMPLETED BY: 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 />$456.00 <br />$760.00 1---X 't Z , I () C c---(%0 CO 3--- <br />I ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNEK <br />TITLE cc1Ii\-)1 AAJA <br />CITY S \c- \-..) <br />Site Mitigation MFR 2-26-2018