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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM 1� <br /> BATE o J 0 1 7- SHADED AREAS FOR E ' JSE <br /> OWNER FILE:COMPLETE PROPERTY OWNERI REBPONBIBLE PARTY INFORMATION: CXOR/OW RTROkMOW LraYJRa1N1N END❑ <br /> PRdeRY I G 1 a i 100 rn °NOME 4 5 f — 1(2_(0 <br /> ONaINNe 3 <br /> taNarPNAra ;,r +-er Cuv-Ae" V r-ky' <br /> CWMRHD1EAD COI(a ATTWI ORCAm OFOPMWIJ f.N <br /> tan R J erAla v / ar Z3-Z.-3 0 <br /> ORI.I rAa,aa AOORma V <br /> IMaaaADDasSORr SrAn Zr <br /> ❑tlarolulTaW ❑Sclvnua ❑PAanmmTF ❑OOVammOAamoY ❑RwraamaPAm ❑OTIRR <br /> ENVIRONMENTAL ❑ EHD Loco VOLUNTARY ❑ RWQCB LEAD- ❑ RWQCSLEAD- <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WOR) 2998 2854❑ OTRC LEAD ❑FE 2954 Ao <br /> 2950 2953 29601352613527 2905 <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEN PROJECT LOCATION MY PREVIOUSLY REGULATED BY THE EmniKiNISIITrAL HEALTH DEPAITIRNYl Yes W No ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEWSCOPE OFWORK7 VES ❑ NO <br /> SIpa66FAdJW/BnWRDlQTNAafi ( I © V M1V(~ 1zo - <br /> SII[AODaaaa/PIID1Ear LooATaw I�"100 7t7w _l0 <br /> tan L_a1- Y-o °Y TEH v gS3-3 O <br /> O011laf OF tIUF61VIPq tTalleOr LOGTpNCoaE Berl HEY! <br /> i YAaan ADDlEae,FDREAEItT RIDM FAcaJry AODAPaa <br /> Ifi a A0011lSS CRY STATE ar <br /> sic COIN COaamr. <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> SIlsma NAra tCA,r�'VL t'� IKP.1iV`1 F-L'bC� SGI�v+[�2.� ATTemDN:Or r.Or(m10AwJ <br /> IMaagADORaa PHOrE <br /> CITY STATE zs <br /> ACCOUNT AOOR[la TO aF11D f>�H AND CMAROFa: OWNER❑ FAGLITYBUSNESS❑ THIRD PARTY BRLINGW <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Onner,Operator,Authorized Agent, <br /> or Responsible Parry 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.l 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/site address, 1 hereby authorize the <br /> release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> ArNnANrNlue(pP fu�.�PaNr) N1{,f'�.GNY l✓l GtvUf9y1 eAaIATIaIa�/ ---_ <br /> TIrIa SI',TryTfl,�S L�//I2,yJr's TAa1D9 V <br /> Mf r W�I�LUO C./I(J LLd�� r« Aa/IDMOTD: <br /> Mt. t oS AODpR oorinmw. O11TE: 1�l <br /> L] <br /> SRTYPE PE SC FEE NFO AMT REMITTED I CHM RECV'D BY DATE smicEREattism NVOICE! <br /> 2903 523 $456.00 �r _ <br /> Work Plan2903 <br /> 523 $760.00 j I!' 2 <br /> Site Mitigation MFR 29-XXX 8-1-2017 <br />