Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE 5/31/2018 SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNERS CURRENTLY ON FILE W/TH EHD <br /> PROPERTY Phil PraSsas PHONE <br /> 949-698-8482 <br /> OWNER NAME --FIR-ST ST <br /> BUSINESS NAME CHI LTH GP, LLC E-MAILADDRESS <br /> OWNER HOME ADDRESS 527 W. 7th Street, Suite 308 ATTENTION:ORCARE OF(OPTIONAL) <br /> CITY Los Angeles STATE CA ZIP 90014 <br /> OWNER MAILING ADDRESS SAME AS ABOVE <br /> MAILING ADDRESS CITY STATE ZIP <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> x❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD— ❑ RWQCB LEAD— ❑ DTSC LEAD ❑FED EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2954 <br /> 2950 2953 2960/3526/3527 2965 <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YESx❑ No ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES ❑ No x❑ <br /> BUSINESSIFACILRY/SREIPROJECTNAME South Lathrop Commerce Center APN <br /> 241-03-013 <br /> SITE ADDRESS/PROJECT LOCATION 800 E Madruga St BUSINESS PHONE <br /> CITY Lathrop STATE A ZIP 95330 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1I KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE CGMMEN/: <br /> REQUESTOR'S INFORMATION: <br /> BUSINESS NAME ENGEO, Inc ATTENTION Ana Lua <br /> MAILING ADDRESS 17278 Golden Valley Parkway PHONE 209-684-7604 <br /> CITY Lathrop STATE :-VA ZIP 95330 EMAIL alua@engeo.corn <br /> ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNER[-] FACILITY/BUSINESS❑ REQUESTOR❑X <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 ACCOUNT ADDRESS for this site. I also certify that all <br /> information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all <br /> applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the <br /> undersigned Owner, Operator,Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby <br /> authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) Ana Lua SIGNATURE ")- /,�- <br /> TITLE Staff Engineer TAx ID# 94-174-8418 <br /> FA III: „y�� OWNERID#: 751, ) .� �/� ACCOUNT#: ,I ASSIGNEDTO: <br /> PR#: :%94346 <br /> /1'K943 /? ACCOUNTING CCOOMb(P,LLETED BY: •LOv DATE: �/¢ <br /> EREK PE ('SjC FEEINFO AMT REMITTED CHECK# RE"BYDATE SERVICE REQUEST# INVOICE# <br /> 2903 523 $456.00 <br /> 2904 523 $760.00 Il' 1 <br /> Site Mitigation MFR 2-26-2018 <br />