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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> DATE 09/15/15 "MFR"-GREEN FORM <br /> SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: <br /> CWECKa OIFWEKMCURKEN2YOW FkEWRW END <br /> PROPERTY <br /> TT PNOME 925-674-8400 <br /> BUNWFBa NAYS ill /. /I9 X,A^C C C(�C E-MAILADORMII <br /> OWNER HONE ADDRESS 1200 Concord Avenue, .Suite 200 J <br /> Cm Concord, CA arA,E <br /> OWNERMAIUNOADORm 1200 Concord Avenue, Suite 200 94520 <br /> """NOA°°"�°8p^ Concord, CA STATE zip 94520 <br /> r ODRPOR,ATpN ❑INDwIDU11L ❑PARTNEMHIP ❑GoyeRrrtNTAGENCY <br /> ❑R®IN]NE1aLE PARTY ❑DnIER <br /> ❑ ENVIRONMENTAL ❑ EHDLOCALVOLUWARY RWQCB LEAD— ❑ RWI]11:1I DR)CLEANUP C TIVE ADTION WATER DUALRYiwDR) ❑ DTSC LEAD El FED EPA LEAD <br /> 2950 2953 2 6 52613527 2965 2959 2954 <br /> FACILITY FILE:COMPLETE 13USINESS/SITE/PROJECT INFORMATION: µ <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YEN [3NoK <br /> IS THIS AN EIIariNG PROJECT LOCATION,BUT A NEW SCOPE OF WORK? <br /> BNNIHEHNtFACILm/$nFJPR(Ap[CT NAPE ' Is p YEN NO El/ I _ I. ��SS �' ' APN: 198-120-09 <br /> Cm ITEAO°"E"'P"'E"L°°"T"' 500 East Louise Avenue, Lathrop, Ca 95330 <br /> BUNINEkN PHONE 925-674-8400 <br /> C <br /> STATE 7JP <br /> BOARD OF SUPERVISOR DISTRICT Lp rioN Com KEW <br /> KEY! <br /> MAILING ADORM,IF DIFFERENT FROM FACILITY ADDREM 1200 Concord Avenue, Suite 200 ATTENTION:dFCARE OFtOPnOW" <br /> N/ <br /> MAIUND Aoomm CRY Concord, CA <br /> STATE zip 94520 <br /> SIC CODE COMMENT: <br /> THIRD PARTY SMILING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BI/NINENN NAME <br /> ATTEHTMIN:MGRE DF(OP)KAWi/ <br /> MNuND ADORENN <br /> PHONE <br /> CnT' <br /> STATE LP <br /> ACCOUNTADDRE9a TOSENNDFEISSANDCHARGES: OWNER& FACILITY/BUSINESS❑ <br /> 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 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 Agen4 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 $AN JOAQUIN OUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my re resentadv,�' <br /> APPLICANT NAPE(PLEASE PRINT) Dana Parry SIGNATURE <br /> TITLE �-1 ( A P. �- ��✓� <br /> TIC lLt�1+' ( °d L�0tAt6Q. ( (J TAIID0 94-1674460 <br /> FAS: <br /> PWNMIIDS:ONI.J1W�Ii, ACCOUNT <br /> S:{�,epp�ll S(o 3 <br /> MNEDO: <br /> -olRlwAKilwal <br /> aaouNti: INvoICE1:�AOOCULMD <br /> Sr. <br /> DATE: <br /> 5-7-2015 ^L <br /> Site Mitigation MFR 29- <br />