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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR GREEN FORM <br /> DATE �I vl /3, o200— 1 SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECI(IFOiVVERISCURRENTLYONFILEWIrH EHD El <br /> PROPERTY PHONE <br /> OWNERNAME t-IRST sr ,70( </2D - 7 <br /> BUSINESS NAME < E-MAILADDRESS <br /> S��e�rlv / �✓�s / a S e i vz's in�r lS e S -- .14e' C.L- <br /> OWNER HOME ADDRESS ATTENTION:ORCARE OF(OPr10NAL) V <br /> CITY / / /� n STATEs�ZIP/ <br /> OWNER MAILING ADDRESS l- <br /> MAILING ADDRESS CITY STATE ZIP <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSI13LE PARTY ®OTHER <br /> [] ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD- ❑ RWQCB LEAD- El DTSC LEAD ❑FED EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2EP <br /> 2950 2953 29601352613527 2965 <br /> 954 <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BYTHE ENVIRONMENTAL HEALTH DEPARTMENT? YES ® No ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES ❑ No <br /> 13USINESSIFAcILITY/StTE/PROJEcT NAME APN <br /> SITE ADDRESS/PROJECT LOCATION � BUSINESSPHONE <br /> SOI/ as:2 d /t/c SL va Ei c /c �GbtAp <br /> CITY kc- <br /> / /"N G,`$TATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT - LOCATION CODE KEY1 - KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS <br /> MAILING ADDRESS CITY STATE ZIP <br /> SICCODE - COMMEurl - <br /> REQUESTOR'S INFORMATION: <br /> BUSINESS NAME .--/ ATTENTION l/ <br /> //uce - (--ciA -e sS6cle <br /> MAILING ADDRESS / PHONE <br /> 30' u c 9/6 37� —/Y3 <br /> CITYSTATE ZIP _ EMAIL <br /> 6L�.s i9 Civ _u.m Wn/ace lc u CO>h <br /> [ ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER[:] FACILITY/BUSINESS❑ REQUEST052 <br /> BILLING AND COMPLIANCE AcKNONVLEDGN 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,ENrORCEATENT CHARGES and/or HOURLY CL&mGGS 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 /> ENVIRONNIENTAL HEALTH DI.:PAwr>vIENT/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�- �u{I SIGNATURE <br /> TITLE ^IS /�adcCcn�o fiU ! �a-iVlor 1-/t/C�IzJ /v¢/i TA%ID# <br /> aG 3fJ� z d'7 J <br /> FAM ,(��' / SI OWNER 10 4: � ACCOUNT#: ASSIGNEOTO: <br /> PR#: - ACCOUNTING COMPLETED BY: - DATE: <br /> (lo <br /> SRTYPE PE SC FEEINFO AIATREMITTED CHECK# RECV'DBY DATE . ('eSERVICEpREQUiSpT#(� INVOICE# <br /> Work Plan 2903 523 $2B•QO;. -- ' '011. b <br /> 290 �$ <br /> Site Mitigation MFR 2-26-2018 ' <br />