Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATe _ F, 'I S SHADED AREASFOR Et1D USE <br /> OWNER FILE I'COMPLETE PROPERTY OWNERI RE�S�rPONSIBLLE'PARTY INFORMAMON: cxrGxrrONNeRrscwrnrxnr�saewnxEHG� <br /> PAOPERw - Li.I✓\_._ /--t / 4rJ'r/,A ki :- PHONE <br /> 4�t�_ 7rxo- 1`3.ra <br /> BwINEa@.NAeIE - - -' FMALADCPeaB <br /> OWNERK"RADO Rua <br /> Om 4 \.. ( .... BTAnr 2P lJ ., <br /> OWNu MR.MdAnemia9" � .. <br /> MARJNO A40REEaCt1' ,,__,,,,/, .. . <br /> SWAM .. YIP <br /> UJ VWOAL OPdmNog"is, OrMANYrar AGENCY ❑RESFONWOUPAmY <br /> vlaoNM01 0 EHDtocALVouwARY j]RWOOBLMA ❑RWOC81.A — .. .. <br /> ASSE36M1:VT 0Lwup 'CORRECME ACITON WATER DMAfY(WOR) d 02959 o [17Y2954 AD . - <br /> 2950. 2953 _ 2980'/3525x3577 8965 .2959 7954 <br /> F 'FILIb COSIPC BUSINESS FSITE/PROJECTINFORNATION: <br /> 19TNIGANEWPROJECTLUOATION&UPmE ouSLYREGuuT BY'mEDmEa"M AL}IEALTNDEPAATMNr7 YES 09 NO O <br /> I""" At' =No PROJEGTIOCATION,BUY AnflYSOOFEbFY1mrN7 YEe❑ RO (� <br /> SYSWFIaIFACamISrtEiPAGRETNAYE-. .. :APN: .. <br /> SnaAooiaasl PaaEcrlxanar Q3O -.�GrS"F C,kar4r Wo: innsnx ;7ma <br /> L $foek-tVM 8"AmcAA 95206 <br /> eonaapFSYP�9AaaRDls[adoT' [ocnrroii.CGoa,' .NEYt '.. --- .KEv2 ... 7 .. <br /> NAIuxa AapgEw,pocreaENi'FaGa RAeam AGOREea . . ArrearlON:oxCAAt OP{ovrrox+y <br /> NAYNd ADDREe9GRY Swe ZY <br /> 1 <br /> IBIOCpde. -. ..- '. IbRaun: ... . . .•.• <br /> T KIPA PJBETY BiLLINO INPO:COM1PLEYEiF EILL NG PARTYIS OIFFERW FROM PROPERTY ONNFA OR RESPON6IBLE PARWIOENTIFIEDABOW. <br /> BYSOINdNAYa (at/,D AI SOIKi'la f: �hC' ATRarmN:oACA OF{OPAQWLJ <br /> 'MAa+xGAuaPEra 3G31yN�sll--�1IVVWilsh7re gew!ruwrcl 1F150i<' PH0N6G213� 3�0-0$-5�- <br /> cm Lot An. : ?4 Bram CA LP 00/0 <br /> ACCGYNrADOREea T0V"DYEEaA,NDONAOO1W OWNRRO FAC(1nV$USn1ESSO THIRD PARTY BRIWO(q <br /> A NC AND COMYlJAfJ(X ACKNOWLEDGMENT: T,the Undersigned Applicant.Certify that I am the Omer,Operator,Audwriwd Agent, <br /> or Respom1ble Party aad I Reim awledge that all PERMtr FILES,PENALT{ES,ENFORCEMBIW CHARGES and/or HOURLY 01ARGES"Medared <br /> with this project will be billed to meat the address identified gboveas the ACCOWTADDRES9 for this site.I also Certify that all information <br /> provided:on this application Istrueand correct,and that alt regulated activities will be performed in accordance with all applicable SAN <br /> JOAQUlN COUNTY OR1D1ttAN(Z CODES and/or STANDARDS'and STATE And/or FEDERAL La WS and REGULATIONS.As the Undersigned <br /> Owner,Operatgr,Aurholired Agent,or Responsible Parry for the project located above under facility/site address;I bereby authorize the <br /> release of any and all results,reports, and other eovironmental assessment information to SAN JOAgUtN COUNrY DMRONmENTAL <br /> HEALTH DEPARTMENT assoon asitia available andtattheseme time itisprovided to me or in esentative. <br /> APILWAMNure.(PlaAse PavlN' i� n�rijW KrvEt Sitl,unme f� <br /> Tma Yy --13 TAx IOY 21/ 261.123 6 <br /> ra UG on <br /> rA4:. p iI- OWN[A WiI: AEAGYNIY lzb YN A991om <br /> OM1'UC.� L ltiLlJ <br /> ACCOUNiV/I/OOM1fRGSJE/aa`eEBeIry1000NeLETEO aY:.- a�- <br /> 6-7-2015 <br /> Site Malgsllon MFR 2B- <br />