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SHADED AREAS FOR END USE <br />CHECK IF OWNER IS CURRENTLY ON FILE WITH END <br />Li 2-911__6 <br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: <br />1 s-?cr9 STATE cA ZN' <br />0 OTHER hiotviouAL CoRPoRATioN 0 PARTNERSHIP 0 GOVERNMENT AGENCY 0 RESPONSIBLE PARTY <br />2sco 1 Kal../C•••• 60( <br />1T j 710 <br />S-36)Y . tl <br />,...PANEP MA41.1%0 ABNIESS <br />104o .r-'t Ca Cm <br />Del-1r I <br />LAST <br />4 c,,,r•rk PROPERTY <br />OWNER NAME <br />E-MAIL Aoomess <br />'Aar 0 et, <br />ATTENTION: ORCARE OF (OPF7ONAL) <br />PE(-(29) 23c71-7 <br />/U_A] <br />FRS <br />k o'v Bus.E. NAME k <br />GANEF, I 'DOE A'.'ENESS soo I r.,_ss Ro4 <br />SAN JC 'UIN COUNTY ENVIRONMENTAL HEALTH " ''ARTMENT <br />SITE MITIL lION MASTER FILE RECORD INFOINI iATION FORM <br />"MFR"- GREEN FORM <br />ENVIRONMENTAL <br />1_ <br />ASSESSMENT <br />2950 <br />EHD LOCAL VOLUNTARY RWOCB LEAD - RWOCB LEAD - DTSC LEAD <br />2959 <br />FED EPA LEAD <br />2954 <br />CLEANUP <br />2953 <br />CORRECTivC ACTION <br />2%0/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />• • <br />FACILITY FILE: COMPLETE BUSINESS I SITE/ PROJECT INFORMATION: <br />Is THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? <br />YES X NO • <br />YES 0 NO X <br />BusiNess/FACILiTY/firrE/PRoJEcT NAME ).._..., 5 og 1 AM+ <br />kA r1 R. 0 0.. <br />i <br />• / 39 - io - <br />SITE ADDRESS i PROJECT LOCATION <br />Lc- 0 o I kck556 ,-, R.. 0 6— 61. " -,— Cm <br />1 rc t ( <br />BUSINESS PHONE 2.09 ...x 3 <br /> 5 <br />, 711 <br />STATE 2, 0 I <br />BOARD OF SUPERVISOR OISTR T i I LOCATION CODE Keel 11 i, KEr2 <br />MAILING ADDRESS ,W DIFFERENT FROM FACILITY ADDRESS <br />MAIL1NO ADDRESS Crry STATE ZIP <br />SIC CODE COMMENT: <br />Ti f'AATY £I&!.INA INT.: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />BUSINESS NAME ATTENTION: OR CARE OF (oanoNAL) <br />14 brie!. <br />MAILING AOORESS PHONE <br /> <br />STATE ZIP <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: <br /> <br />OWNER!: <br /> <br />FACILITY/BUSINESS0 THIRD PARTY BiLLING0 <br />BILLING AND COMPLIANCE ACKNOMLEDGMENT: 1. the undersigned Applicant, certify that I ani the Owner. Operator. Authorized Agent, <br />or Responsible Party and I acknowledge that all PERMIT FEES, PE.V11.TIES, ENFORCEMENT OIARGES and/or Hot RI)CHARGES associated <br />with this project will be billed to me at the address identified above as the Accouvr.looREss for this site. I also certify that all information <br />provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN <br />JO-SQL IN COUSIN ORDINANCE CODEs and/or STANDAHus and Si ATV. and/or FE1)LRA1 Laws and REGULATIONs. As the undersigned <br />Owner. Operator. Authorized Agent, or Responsible Party for the project located abov e under facility/site address, I hereby authorize the <br />release of any and all results, reports, and other environmental assessment information to SAN .10\Q( IN COUNTY ENviRoNNIENTAt. <br />I-1F &Ft H DEPARTNIEN1 as soon as it is available and at the same time it is provided to me or my repres tative. <br />APN K.A0 54 '.ME (Ft ASi 'ANTI Ot,krie,- <br /> <br />S.t.-P•LATIJAE <br /> <br />et5 <br />T-ra• C:)L.Jrv,i2e- <br />FA OWNER IO N: accounTS: ASSIGNED TO: <br />rig CO2-3 2--q 1/4c- hn)—,1S05- 74tAion,-2si,3 <br />P • ACCOUNTING COMPLETED BY S)- R <br />DATE: <br />9-3-2015 <br />Site Mitigation MFR 29-