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SAN JCIAQUIN COUNTY ENVIRONMENTAL HEALTH nEPARTMENT RECEIVED <br /> SITE MITI BION MASTER FILE RECORD INFG. CATION FORM JUN 1 .I 2016 <br /> "MFR"-GREEN FORM <br /> DATEZO WWWACWAU�€�4 USE <br /> PERM FFISERV(;E'� <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNERS CURRENTL YON FILE WITH EHD <br /> PROPERTY PHONE <br /> OWNER NAME FIRST MI LAST 209— 3 - 3 245 <br /> BUSINESS NAME (( E-MAIL ADDRESS <br /> OWNER HOME ADDRESS l ATTENTION:OR CARE OF(OPTIONAL) <br /> CITY $TATE ZIP <br /> r06 C-V <br /> OWNER MAILING ADRESS <br /> G <br /> MAILING ADDRESS CITY .,/ STATE ZIP <br /> E:1 CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP H GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY RWQCB LEAD— ❑ RWQCB LEAD— ❑ DTSC LEAD ❑FED EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2954 <br /> 2950 2953 296013526/3527 2965 <br /> -ACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES V NO ❑ <br /> BUSINESS/FACILITY/SITE/PROJECT NAME APN: <br /> Ae1ao. �an� la � 100 1 - TO-05 <br /> SITE ADDRESS I PROJECT LOCATION BUSINESS PHONE <br /> tin 2-2- <br /> CITY $TATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS <br /> tAg.',k : 1\ <br /> 1 <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ATTENTION:ORCARE OF (OPTIONAL) <br /> MAILING ADDRESS PHONE <br /> '1 O - 4 20- <br /> CITY �m CTE ZI1� <br /> 440 g <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING <br /> ifLLING AND COMPLIANCE ACKNONVLEDCNIENT: 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 /> vith 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 /> wovided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN <br /> [OAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned <br /> ?caner, Operator, Authorized Agent, or Responsible Party for the project located above ander facility/site address, I hereby authorize the <br /> •elease of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> iEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my re resentative. <br /> APPLICANT NAME(PLEASE PRINT) `_!� �tl SIGNATURE <br /> TITLE S4z,-F-F Gc,2ITAX ID# 46- 12Z9--1zZ4 <br /> FA#: OWNER ID#: ACCOUNT#: ASSIGNED TO: <br /> �,Qodz3SLS Du1�;24��� Q60y3�dg <br /> PR#: /� � ACCOUNTING COMPLETED BY: DATE: <br /> f-3-2015 <br /> lite Mitigation MFR 29- <br />