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F <br /> SAeOAQUIN COUNTY ENVIRONMENTAL HEALTHt*PARTMENT <br /> DATE G, 1� Za( MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> t G SITE MITIGATION&LOP <br /> SMADED AREAS FOR EMD USE ONLY OWNER 1011 CASE/ UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER 18CURRENTLYONF7LEWim EHO 0 <br /> PROPERTY OWNER NAME ! ` <br /> FIRST MI UST PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> RD I NVaTMENTS INC <br /> OWNER HO�M,EJ ADDRESS <br /> -1 E WA-TEP-L00 F-D <br /> CITY sTo( ro +� <br /> �./tTS7ZIP <br /> OWNER MAID ADDRESS (��- t/I <br /> S � IN�T��LOo RLQ <br /> 1b1iLINGADD'TT �TU <br /> 11 Ni t'j T�- zP S21 S <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY 100 INVM AccouNr10 PRN/ROS ABBIGNEDEMPLOYEE I LEAD AGENCY:EHD_RWQCB_OT8C_EPA <br /> _ <br /> FACILITY FILE:COMPLETE BUSINESS 1 SITE/PROJECT INFORMATION: <br /> IS THIS ANEW PROJECT LOCATION NOT PREVIOUSLY REGULATED SYTHE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NOV <br /> ISTHIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES-V No ❑ <br /> BuSINEBS/FAc11JTY/BrrEIPROJECT NAME <br /> SITE ADOREaS f PROD C7 LOCATION SURE* 13USINVIS PHONE <br /> lj'�15 !VA'T- o M1r9) -g 2 <br /> CITY STo/�{_�Ot .1 I STATE JJP 1�1 S <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY22 <br /> MAKING ADORM,IF DIFFERENT FROM FACILrrY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> iU� DR. S uI ori- CP-ISTIN4 <br /> MArhINGApO ESS CC)?1 _ ` r� PLTITE ZIP <br /> SIC COODEg1 l// �/ APPNN 0 CoMMENr. l� <br /> THIRD PARTY BILLING I NFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESSNAME h' 1 , `1 ��S,tq� U —,Eppp <br /> j�1 t AT'CENTKIN:ORCARE OF(OPTIONAL) <br /> MAILING ADDRESS ZO�yq� S- <br /> W I L M II N I�lJt-� V l (CJ PHONE 251 13-I l 6 <br /> CITY CA'RSd� STAJE J ZJP OCA <br /> /I <br /> ACCOUNT ADDRESS TO SENO FEES AND CHARGES: OWNER❑ FACILITY/BUSINES THIRD PARTY BLLINV <br /> HILLiNC AND CDM PLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certifi•that I am the Onrner,Operator,Authorized Agee,ar Responsible PmYv and I acknon ledge that all PER.UIT FEES, <br /> PEN.4Lt7ES,EAFORCEI/E.VT CIL4RGES aild/or ljuttiLi-CD.4RGts associated with this project will be billed tome at the address identified above as the ACCOL:YTADDRESS for this site. I also certify that all <br /> information provided on this application is true and correct•,and that all regulated actnities Fvill be performed in accordance with all applienMe SAN JOAQUIN COUNTY ORDINANrE Cowre and/or <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the aSdersigaed Oaner.Operator,Authorized Agent,or Responsible Party for the project located above under facility/site address, <br /> hereby authorize the release of any and all results,reports,and other endronmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as S0011 as it is available <br /> and at the same time it is provided to me or my representative. G�k �,� <br /> APPLICANT NAME(PLEASE PRINT) 7-`Pv CT 40Y� �VILUjJ3' ,J SIGNATURE / t S N�cs E.t>-�.,x, <br /> TITLE 1 JJJ a-a UrFF{�ll TAXID* <br /> APPROVm BY DATE AoCOUNrNOOFFicE PRocsmm COMPLETED BY OATS <br /> SITE MfTIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT A CHECK# RECEIVED BY WORK PLAN PE <br /> FEE:; <br />