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ATTENTICW )a44 fft-Avvri <br />PHONE <br /> <br />ZIP <br />EwAL31f-ilio e 5 <br />Smogs NArt <br />"LING Acmes 3330 <br />Pc <br />MN\ PcitiC Di v 5$° <br />STATE CA-- <br />SAN J0k, _AN COUNTY ENVIRONMENTAL HEALTH DL .ZTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />Dxre D-I1- 406 SHADED AREAS FOR EHD USE <br />OWNER FILE PARTY INFORMATION: CHECK : COMPLETE PROPERTY OWNER/ RESPONSIBLE IF OWNER IS CURRENTLY ON FILE WITH END 0 <br />PROPERTY <br />Ovniat NAME f-INCk 16 a/ .1V4 <br />PHONE <br />kl- -1S-- 3774 FIRST MI LAST <br />Buseass NAME 110., e-"LAcenels-rio,d 6a/a) (2,fatied <br />c Omen How Asonsla cr--H1 q ^A64+‘ Vci lie if i) ‘e-t- <br />ArnamoN: OR CARE OF (OPT/OAHL) <br />Orr (-_; -vvk STATE (A_ zr 75;20 ci <br />OWNER MAKING AGGRESS <br /> <br />lilmuNo ADDRESS CITY STATE ZIP <br />0 CORPORATION INDIVIDUAL 0 PARTNEnsepo 0 GOVERNMENT Aostcy 0 REEPONMSLE Parent 0 Ones <br />ENVIRONMENTAL EHD LOCAL VOLUNTARY V RWQCB LEAD - <br />- CT1VE ACTION <br />2960/3526/3527 <br />RWQCB LEAD - <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />WATER QUAUTY (WDR) <br />2965 <br />DTSC LEAD 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? YES El No)iif <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES V No 0 i (0333aaj <br />BUSINESWFAGEMYSITEIPROJECT NAME tioct lit A i.t.t4, ‘ <br />i <br />)11 <br />U77 „(/ (7015 (iput APN Imo I (0 <br /> ..;C3 06)Z <br />SITE Moans/ Prom= LOCATION et <br />j <br />, <br />)6111 U 66t 'DA A Zoxidail (biihik, bi.v viiii5 .4-1(3)77,7,1PH°NE) )(to <br />c" 5 Li/ coA STATECt ZIP <br /> <br />BOARD OPSUPHIVISOR DERMOT I I LOCATION Cooe I 1 Kari 1 I- kw j <br />MAIUNG ADORERS, W DIPPERENT PROM FADIUTY ADORERS 'p , . (A , -7 kA $400 , Li I ) <br />MAiuna Amuse Cm <br />56U:1141'1 <br />STATIO_ ZIP ..)s• 8 3 y <br />st0 CODE Ookumwr: <br />REQUESTOR'S INFORMATION: <br />I ApoouN7 ADDRESS TO SEND FM AND CHARGES: OWNER0 FACILITY/BUSINESSE RECUESTORX rail') I <br /> <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 scion as it is available and at the same time it is provi ed to me m representative. <br />/Optima NAME (Puma PRINT) jr7 1 1.4 (hCIA SIGNATURE <br />TITLE 0\51, P -P-117 TAX ID* <br /> <br />FA L F-4 an 2413 4, omen io #: ow60236a.. 1 Accoutrr 0: M004 7:311., ASSIGNED TO: <br />PR it e-) riq 0643 E-Ss- ACCOUPTNO COMPLETED BY 7//70 DATE: //2 // g <br />INVOICE# SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVT BY DATE SERVICE REQUEST# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 ° -, ° -i 1 i ' <br />° - I , t 1- I ..' • <br />OPA4 <br />Site Mitigation MFR 2-26-2018