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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH 10PARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"- GREEN FORM <br /> DATE I Z� I O SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CNEORYFORWeRYSCaRREMLYORFneNNrN EHD <br /> PROPERTY PHONE <br /> OWNERNAME i FIRST MI LAST — Z— Sq <br /> BUSINESS NAMEar EHIIAILAwma <br /> Ora 11'�T <br /> OWNER HOME ADDRESSATTENDON: E 0 J <br /> l� <br /> Cm -T ST TE ZIP <br /> OWNER MAILING ADORESB <br /> 1AAIUNGADORESSCITY STATE ZIP <br /> CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY RWOCB LEAD- ❑ RWOCBLEAD- <br /> ASSESSMENT CLEANUP CORRECTIVEACTION WATEROUALITY(WDR) ❑ DTSCLEAD ❑FEDEPALEAD <br /> 2950 2953 2960/3526/3527 2965 2959 2954 <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS ANEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ Nog <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OFWORK? YES ❑ NO N <br /> BUSINESSIFACILITYIS"EIPROJECT NAME w/A?I� G? Ir /C./04e / 1 IN, , 1 <br /> SITE ADDRESS I PROTECT LOCATION ` INES PNONE `-i <br /> W r STr�e - <br /> Cm h $TATE ZO <br /> BOAROOFSUPERVISORDISIRICT LOCKDONCODE KEY1 KET2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS <br /> MAILING ADDRESS CITY STATE ZIP <br /> SICCODE 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 OP <br /> rl Q/ OF I <br /> MAILING ADDRESS PHONE <br /> Cm 9T TE ZIP <br /> ot Lms- <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS[-1 THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 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 ACCOUNTADnRESS 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/siteea�a4dress,I hereby authorize the <br /> release Of any and all results, reports, and other environmental assessment information to SAN JOA(6N COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my/reeFgresentative. <br /> APPUCANT NAME(PLEAIE PRINT) Sr,O77 ( 7rniar/ SIGNATURE ,I�✓'!;�- <br /> TrnE / TAXIDN <br /> FAR: 23�q OWNER ID i1OO�`��q ACCOUNT>t: � � I (n ASSIONEDTO':Y <br /> PRN: L001271 T ACCOUNTING COMPLETED BY: � DATE: <br /> 9-3-2015 Ll <br /> Site Mitigation MFR 29- <br />