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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE / Z O Z t7/ (p SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTYOWNER/RESPONSIBLE PARTY INFORMATION: ONear��0►trvsq/sCuRgsNnYoYpi(s�wny EHD El <br /> 541 a,r <br /> PROPERTY � ro h 1 , e^•r O PHONE �,� ��� �sn O <br /> OWNERNAME irrsr I� '` KST <br /> BUSINESSNAME �,�n C (�LS L./_ s aryl �Je^r/•C /1� n„ E-MA]LADDRE'-5L.RL e—. Com <br /> OWNER HOME ADDRESS [/1 NA <br /> C KATTENTION:URCARE OF(01077"L) <br /> CITY STATE zip <br /> OWNER MAILING ADDRESS 3 V O I Croo C'any o x Road <br /> MAILING ADDRESS CITY a ^M O„ l.• STATE zip QN��2 <br /> *ORPORATION El INDIVIDUAL El PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY / ❑OTHER <br /> ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD— ❑ RWQCB LEAD— W'DTSC LEAD ❑FED EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) <br /> 2950 2953 2960/352613627 2965 2959 2954 <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJ ECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> I S THIS AN EMSTING PROJECT LOCATION,BUT A NEWSCOPE OF WORK? YES No ❑ <br /> BUSINESS/FACILITY/SITEIPROJECT NAME J::OrM e r APN: D q t''3 20 <br /> _ 0 t0 <br /> / <br /> SITE ADDRESS/PROJECT LOCATION 7/ 2. S. So crL1^K meittoo ("S CG+' BUSINESS PHONE MA <br /> CITY 4 0'a6'' STATE zip q S-2 5(D <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS Vcar4- Lo t <br /> CL <br /> MAILING ADDRESS CITY STATE zip <br /> SIC CODE COMMENT: <br /> THI RD PARTY BI W NIG I NFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED AB OVE. <br /> BUSINESS NAME l e^r„ra ?^[C/ / 67rOU^ S14: <br /> ''' +I q n ATTENTION:QgCARE OF(QPT7lyY4('nAli/ /,�r,On6s <br /> MAILINGADDRESS 131300 00 t7/ATOLL -park-Way'F+ J 14 I e / L I PHONE 674— 9"7-K((L(/ �,L,JV xZZ3 <br /> CITY STATE C In zip Q� /�/ ? <br /> r✓'h i"l ( lU <br /> ACCOUNTADDRESS To SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE.ACKNONVLF.DG.%IENT: 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,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated <br /> with this project will be billed to me at the address identified above as the ACCOUNTADDRESS 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 /> JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned <br /> Owner, Operator,Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby authorize the <br /> release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) Pala SIGNATURE -� <br /> TITLE �rl�he a /v�. CTee f�j�' TaxID# 20 --32332-77 0 " 2 2 33 2 ( 7 <br /> Kc J -- <br /> FA#: OWNER ID#:. ACCOUNT#: I ASSIGNED TO: <br /> PIR#: ACCOUNTING COMPLETED BY: 1 DATE: <br /> 9-3-2015 <br /> Site Mitigation MFR 29- <br />