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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH 11- PARTMENT <br />SITE MITI. ''ION MASTER FILE RECORD INFO, ,ATION FORM <br />"MFR"- GREEN FORM <br />DATE 1‘-2.-1-7, 6 I -3-- SHADED AREAS FOR EHD USE <br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD <br />PROPERTY <br />OWNER NAME <br />KcNr % 13e.,0 i 1 PHONE <br />li ti - 611 -. 3-44 8, FIRST MI LAST '-' <br />BUSINESS NAME E-MAIL ADDRESS <br />OWNER HOME ADDRESS ..... "--• 1 --1 73 c ...3 i c , ,)-1-ctA.e. e_c, it e..5, st,,,), gc,„„ 5 031.- ATTENTION: ORCARE OF (OPTIONAL) <br />CITY ,. es STATE apt ZIP ci z i 1 <br />OWNER MAILING ADDRESS <br />o.3O - <br />MAILING ADDRESS CITY STATE ZIP <br />0 CORPORATION INDIVIDUAL PARTNERSHIP 11 GOVERNMENT AGENCY Ni RESPONSIBLE PARTY 0 OTHER <br />111 ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />111 END LOCAL VOLUNTARY <br />CLEANUP <br />2953 <br />Cgl RWQCB LEAD - <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />RWQCB LEAD - <br />WATER QUALITY (WDR) <br />2965 <br />LI DTSC LEAD <br />2959 <br />El FED EPA LEAD <br />2954 <br />FACILITY FILE: COMPLETE BUSINESS! SITE/ PROJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? Ys l=1 No IE <br />Is THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES LN No 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME <br />FO rf', 4-f.' CAUZ,V't'D ^ cA ? 6 3 z. APN: <br />SITE ADDRESS / PROJECT LOCATION cl c 0 c.44- Gr,..-...4- 1..-,, 14-04 C) BUSINESS PHONE <br />CITY .1.-„..0 STATE .ZIP <br />ci s 3 -7 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE Keel Kea <br />MAILING ADDRESS, IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />SIC CODE COMMENT: <br />THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> <br />BUSINESS NAME (714130 ATTENTION: ORCARE OF (OPTIONAL) <br /> <br />MAILING ADDRESS t9 3 Rtse-csii..tv - <br /> <br />PHONE A LG . ti 14 - o 19 <br />STATE ZIP CA <br /> <br />CITY <br /> <br />I ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNERD FACILITY/BUSINESSE THIRD PARTY BILLIN4 <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Ageni <br />or Responsible Party and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associatei <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 informatioi <br />provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable Sr <br />JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersignel <br />Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby authorize th <br />release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENYIRONMEN'FAI <br />HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />APPLICANT NAME (PLEASE PRINT) g e,e‘ SIGNATURE <br /> <br />TITLE TAX ID # 114 - izzen <br />FA #: re440.2.4_,3 wig, OWNER ID #:01V0(....)22 (13.51 ACCOUNT #: Akoff76--(7L 28- ASSIGNED TO: <br />PR #: s _4.2,41 22) ACCOUNTING COMPLETED BY: DATE: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE SERVICE REQUES # INVOICE# <br />2903 <br />2904 <br />523 <br />523 Work Plan I- <br />$456.00 <br />$760.00 - )( V2— KII1 Sc_4io1 eif 5-1 5 <br />Site Mitigation MFR 29- XXX 8-1-2017