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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> Dnre 8- 1 -Ito SHADED AREAS FOR END USE <br /> OWNER FILE i COMPLETE PROPERTY OWNER.RESPONSIBLE PARTY IN FORMATION: CHEM OWER 0 GWRIHraroxFUEIM END� <br /> PmP art 1 Q I CLQ. i PNoac <br /> owNen NAME RST 9p4�- `fa4 -3tr43 <br /> BaewEeaNAMe St?X CW aJl?fM TIt°e",IAv alaLlc�(vs . Corti <br /> OWNER HOME ADDRESS 1332R�-A Lull ant nQ. (/Yci+e ATTellnoa:ATCAAEOF(GPP ) <br /> rlav Char ID 4e STATE tJ G ZIP <br /> 0WNERMAIua°AaaRE6e .XINVIL OSS 0.-10 PVQ <br /> fi( . ADOamcav STATE ZIP <br /> SANK c�S O.AOOVO- <br /> C°NPOAATIoN ❑INDNIOUAL ❑PARTNEAWP ❑ODvestiu RA0ENDY 0RESPGNSO1sPARri ❑OTHTA <br /> ❑ENVIRONMENTAL ❑ EHDLOCALVOLUNTARY ❑ RWQCBLEAC– ❑ RWOCBLEAa– qq�1 <br /> A95E85MENT CLEANUP CoRREcnvE ACTION WATER QUAL"CINDR) 2959 2854 <br /> K+ DTSC LIian ❑FE 2954 Ao <br /> 2950 2953 1 28601352813527 2885 <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> ISTH13A NEWFROJECTLOCA710N NOT PREVIOUBLYREOUTATED SYTHE ENVIRONMENTAL HEALTH DEPARTMENT? Yes ❑ No 19 <br /> IS THIS AN EXISTING PROJECTLOOATION,BUT ANEW SCOPE OFWORK4 Yes ❑ No Rl <br /> BUGMESSIFACUMI9aE1PROJECTNAME SPX Mavle APN: 14331004 <br /> SRBAoDsina/PROJEDFLOCARON ac�o (JTx+v% Wa vlev' AveBUSINESSPHONE <br /> Cm 'r Er A r'P G 5 2 I S <br /> SOARa OFSUPERVbOA IkaTRwr LGCATION CODE KEY! KEY2 <br /> MNONGAGDREE9,M01FFEREMFRaM FACRmADoaEAB t33z0 -A '$all avl} ne CDr cvo.4e PI . ihfN: Waliv( G—ala <br /> MAnnloADOREMCm ( I }fit? 8NL 7JP 'Ua <br /> SICCODE COMMENT: <br /> THIRD PARTY BILLING INFO.-COMPLETE W BIWNa PARTY 15 DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME MWN e/'(IC46 Q'IT- 1hva I't (omawy ekC Rowne <br /> MAaJNa AnOREEa g30I L S't Su A-e t900- PHOME 91 to- e4 IS-(d3G <br /> 0, C'CXCNMMeA*M STATE GA LP 9S61tp <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FAcunrylBttSWESSp THIRD PARWHILLINOO <br /> BmLTNO AND CcrPLTANCE ACKN0wLEl1G=ff I,the undersigned Applicant,Certify that I am the,Orvnet,Operator,ARtlrorrkrdApiT4 <br /> or.Responsible Party and I acknowledge that all PER3I7T FSEs,PENAc7=,ENF0ACmiEAT CHARGEs and/or HOURLY CHARGE4 associated <br /> with this project will be billed tonic at the address Identified above as theAccouNTADDREsv for this site.I also certify that all information <br /> provided on this application is true and correct; and that oil 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 REGIILATIONs. As the undersigned <br /> Owner, Operator,AuBmrized 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 JOAQuDN Cowry ENVmONatENTAL <br /> HeALTRI)EPARTAmxr as soon as it IS available and at the same time It Is provided to me or my rr'e-prre`sentative. <br /> APPUCAKr NAME(PLFAsliftai) WQIi-e CT0.t0,CkC:, SIGNATURE <br /> T— CT10bal Dzettl-o(t EnVvyonlYfCY4c1{CRI WI y. C„p(e.).,JrAxtos 1 <br /> FAO: OMMERIOk ACCODN�r✓JP. =TO: <br /> PRO: AGODUNTINOOOUKMODY: OATS; <br /> 9-3-2075 <br /> Site Mitigation MFR 29- . <br />