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N SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION MASTER FILE RECORD INFORMATION FORM "MFR"- GREEN FORM DATE I o l l S i Z 1 ❑ RWQCB LEAD- SHADED AREAS FOR EHD USE OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK/FOoswERIBC[IRRENnyoNF/LEmm EHD PROPERTY OWNER NAME I„/ (-k Y� -& �'l� WATER QUALITY (WDR) PHONE (Z' S-6) Sbv - 218 q S )RST I M1 I LAST 2953 BUSINESS NAME ��&Ioa mrvvt r o C.. 2965 E-MAIL ADDRESS OWNER HOME ADDRESS I ` O ZY��1 N T ATTENTION: ORCARE OF (OiPrWNAL) CITY 7bf-u r STATE L LP 35-(.o OWNER MAILING ADDRESS C 2 MAILING ADDRESS CITY �e C Y STATE /I L ZIP 3 S 6 1 /PARTY CORPORATION [:1 INDIVIDUAL ❑ PARTNERSHIP ❑ GOVERNMENT AGENCY El RESPONSIBLE ❑ O1NER Ig ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD- ❑ RWQCB LEAD- ❑ DTSC LEAD ❑ FED EPA LEAD ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY (WDR) 2959 2954 2950 2953 2960/3526/3527 2965 MAILING ADDRESS CITY 5 2 STATE FACILITY FILE: COMPLETE BUSINESS/ SITE/ PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES m IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES ❑ No ❑ No ❑ BUSINEWFACILITYISITEIPROJECr NAMEAPN ao n t -?\ .'%+ o - d , o o SITE ADDRESS/ PROJECT LOCATION Z3°Il5 CoL -`lt MI14vn fZ A BUSINESS PHONE C-LO-A)L300 Cm nden L1 CA srA ztP 95 -L 3 6 BOARD OF SUPERVISOR DISTRICT LOCATION CODE 11 KEY') WllKEY2 11 MAILING ADDRESS, IF DIFFERENT FROM FACILITY ADDRESS RE /R,EQUE(JST# 008 MAILING ADDRESS CITY 5 2 STATE ZIP SIC CODE COMMENT: hot 11% COON 13� REQUESTOR'S INFORMATION:r. BUSINESS NAME % _+ I I Q `jEALTN D ATTENTION MAILING ADDRESS PHONE Z UO.I C Y -Lw Cant' Ur, S� �4� L I o = � - CRYSTATE ZIP- EMAIL - n 1�a'N Gr1 �5'�3 Ivt��v,11�c,b�v �b; �ticca dj, ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNER❑ FAC[Lrry/BUSINESSI <51EQUESTO BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, or Responsible Party and I 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 information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. APPLICANT NAME (PLEASE PRINT) MI (✓�� `1 e YWD� SIGNATURE I� TITLE ?i.L-I C-7-P-0I0 r 1$t 1 TAxID# FAX: OWNER IDiI:�%/,j�/�� C CL�2 ACCOUNTiI: AJ/C�] ASSIONEDTO: PRM � �4^��j -'.ACCOUNTING COMPLETED BYf:-J J/J ft / J / DATE: SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE INVOICE# Work Plan 2903 523c�`7 J I 5 L /R,EQUE(JST# 008 2904 523 $760..00 ✓ 13� v Site Mitigation MFR 2-26-2018