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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />I'MFR GRFFN FORM <br />DATE <br />I vl / 3 , <br />o20a- 1 <br />❑ RWQCB LEAD- <br />SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: <br />CHECI(IFO{YNERIs CURRENTLYONFILEWITH EHD El <br />PROPERTY <br />OWNERNAME <br />WATER QUALITY (WDR) <br />El DTSC LEAD <br />El FED EPA LEAD <br />2950 <br />2953 <br />29601352613527 <br />PHONE <br />;JCS l </ 2'D - 7 <br />t-IRST <br />MI <br />LAsr <br />STATE <br />BUSINESS NAME // <br />S 7/cC tU�( <br />„(/ / <br />G✓E S / a S E <br />L // <br />-2''C-S fr1 PiV % 4 C <br />E-MAILADDRESS <br />j - - . 14 _.G ZQ�Civnle</ <br />OWNER HOME ADDRESS <br />1t�/D� %YYM� )' <br />ATTENTION: ORCARE <br />>D�w � F'lvo.^• <br />OF(OPl10NAL) V <br />,�enlivlpar <br />CITY / / /� <br />STATE Sc5 Z� ! <br />OWNER MAILINGADDRESS <br />MAILING ADDRESS CITY <br />STATE ZIP <br />❑ CORPORATION <br />❑ INDIVIDUAL <br />❑ PARTNERSHIP ❑ GOVERNMENT AGENCY <br />❑ RESPONSI13LE PARTY MOTHER 44C! <br />[] ENVIRONMENTAL <br />❑ EHD LOCAL VOLUNTARY <br />❑ RWQCB LEAD - <br />❑ RWQCB LEAD- <br />APN <br />06 <br />ASSESSMENT <br />CLEANUP <br />CORRECTIVE ACTION <br />WATER QUALITY (WDR) <br />El DTSC LEAD <br />El FED EPA LEAD <br />2950 <br />2953 <br />29601352613527 <br />2965 <br />2959 <br />2EP <br />FACILI'T'Y FILE: COMPLETE BUSINESS / SITE/ PROJECT INFORMATION: <br />IS THISA NEW PROJECTLOCATION NOTPREVIOUSLY REGULATED BYTHE ENVIRONMENTAL HEALTH DEPARTMENT? <br />IS THIS AN EXISTING PROJECT LOCATION, BUT ANEW SCOPE OF WORK? <br />YES ® <br />YES ❑ <br />No ❑ <br />No <br />BUSINESSIFACILTTYISTTEIPROJECT NAME <br />�s2< a� <br />APN <br />06 <br />6; <br />SITE ADDRESS/ PROJECT LOCATION � <br />Sail a :? d /t/ c SL va Ei c /c �GbtAp <br />BUSINESSPHONE <br />CITY kc- <br />/ /"y <br />G, `$TATE <br />ZIP <br />BOARDOPSUPERV15ORDISTFRCT - LOCATION CODE KEY1 - <br />KEY2 <br />MAILING ADDRESS, IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS CITY <br />STATE <br />ZIP <br />SIC CODE - COMMENT: - <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ REQUEST052 <br />BILLING AND COMPLIANCE AcKNONVLEDGI1' ENT: 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, ENrORCENIENT CHARGES and/or HOURLY CHARGcs 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 Parry 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 />ENVIRONhIENTAL HEALTH DI;PAwrNIENI' /as soon as it is available and at the same time it is pro"ed to me or my represents 've. <br />APPLICANT NAME (PLEASE PRINT) 6��aG� - �uil SIGNATURE <br />TITLE ^IS �adcCcrnO fiL �a-iVlor 1-�c�/C�i0 /v¢/i TAXID# <br />FA 9: ��'OWNER 10 4: %'�r� ACCOUNT#:�%j1Q'xd ASSIGNEOTO: <br />PR#: �J ACCOUNTING COMPLETED BY: "_ DATE: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DE�Rr;VICE RREQUESTT# (� INVOICE# <br />Work Plan29Q3 523 $B.60; 1 <br />Site Mitigation MFR 2-26-2018 - " � ' r �� <br />%1 WYl <br />