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Receive° <br />DEC SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ur <br /> '3 408 <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM IDpI <br />"MFR"-GREEN FORM N7 tH <br />DATE December 12,2018 <br />SHADED AREAS FOR EHD USE <br />I OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: <br />PROPERTY <br />OWNER NAME <br />( AA' I <br />8""E <br />55 <br />N -E e A2ZVi 7-y Mtzy-c-4 <br />OWNER HERM ADDRESS .7 z 0 <br />cn, ,5 7---ok o AJ <br />OWNER MAILING ADDRESS <br />ATTENTION: ()STARE OF (ornoni.41.) <br />LAS7 <br />CHECK IF OWNER IS CURRENTLY ON FILE WI774 END El <br />artrale.5 e cince.iers.L5 <br />PHONE <br /> ?73 276 3 <br />cV-io <br />MAIUM3 ADDRESS CITY <br />STATE <br />‘460ftPORATION 11 INDIVIDUAL PARTNERSHIP El GOVERNMENT AGENCY 0 RESPONSIBLE PARTy El OTHER <br />0 ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />E EHD LOCAL VOLUNTARY <br />CLEANUP <br />2953 <br />E RWQCB LEAD — <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />Li RWQCB LEAD - <br />WATER QUALITY (WDR) <br />2965 <br />ILi DTSC LEAD <br />2959 <br />Li FED EPA LEAD <br />2954 <br />FACILITY FILE: COMPLETE Busi • <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT-? YES D No [7( Is THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE Of WORK? YES CR NO E <br />BusINEserrAcilITY/SRFJPROJECT NAME 72 c> 6--,1 '/44,4 E., t sz,-7 I APN - ''13 C <br />1 1 .-27*-ACT)' -660 SfrE ADDRESS / PROJECT LOCATION ---7 ? 0 -..i./.4.4.4),„.:::::- • <br />BUSINESS PHONE <br />Crrr .67-0 c-ic-TGRI c,s4E zip ....2e2_. Scum OF SUPERVISOR DISTRICT j ! LOC.ATION CODE '' 1 Keil r Keil I 4.... MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS <br />6 W Alk tL- AZ a 11-1? - S /Mw <br />—.L. <br />SWUNG ADDRESS CRY STATE ZIP <br />SIC CODE Cosmatr. <br />REQUESTOR'S INFORMATION: <br />BUSINESS NAME <br />eSc•eenL4.7. 1 <br />1 <br />ATTENDON <br />Rcoert Fagerness <br />MAIUNG ADDRESS <br />11249 God Co..imry Blvd., Ste. 165 PHONE <br />916-288-8170 CM <br />0.:147 R:ver STATE <br />CA ZIP <br />9567C EMAIL <br />itagerrtessgescTerlogc.corn <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNERO FACILITY/BUSINESS:I REQUESTOR V <br />I BILLING ANII Cf17140I TA Vry A r.t,muy r,-...-,....,,.,..-. v ... _ ____ _. . . .. . . . . . . . , . e, uie unaerstgneupp ican cern y that I am the Owner, Operator, Authorized Agent, or Responsible Party and [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 <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 andlor 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 assessmen nformation to SAN JOAQUIN FOUN ', <br />EVIRONN1ENIAL HEAL Ili DEPART] ENT as soon as it is available and at the same time it is pr d to me o <br />7 <br />r mv tatly <br />APPUCANT NAME (PLEASE PRINT) ex 6-4...zi 1 eQ)crizt SIGNATURE <br />AuthonzeS lent eti-/- 1-7-x4e-red-c- rieCeck 2- ' <br />PAL: FA ce),2.57)/0 <br />.) <br />OWNER ID*: 0 Wooz3(.75-- Accouurs: e7-)412>-.. p si RAs4/3767 ACCOUNTING COMPLETED sY: <br />0 DATE SR TYPE r PE SC FEE INFO Me REMITTED CHECKS RECVD BY DATE SERVICE -;ME.6.t. II i INVOICEJI <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />S456.00 <br />$760.00 ] -; x, ?SI 2_1411 L > <br />. <br />1 t IOU S C3FrJOO 6 <br />TAX MO <br />Site Mitigation MFR 2-26-2018