Laserfiche WebLink
SAN JO. —JIN COUNTY ENVIRONMENTAL HEALTH D. ,RTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE `l_/D -,?,0/ SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECKIF OWHER/3 CURREAm YOHFILE WITH EHD 3 <br /> PROPERTY r .� _ PHONE <br /> OWNER NAME IRSr ST <br /> BUSINESS NAME n E-MAIL ADDRESS <br /> OWNER HOME ADDRESS K -5 ATTENTION:ORCARE OF(OPTIONAL) <br /> CITY G C�/� J STATE ZIP (J/ / <br /> OWNER MAILING ADDRESS IC <br /> MAILING ADDRESS CITY STATE ZIP <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD— R 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? YES ❑ No <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES © No ❑ <br /> BUSINESSIFACIUTYISITE/PROJECT NAME APN <br /> 7— (50-3 <br /> SITE ADDRESS I PROJECT LOCATION ( ( BUSINESS PHONE <br /> ���1 -mite i31 V� Sf <br /> CITY STATE CA ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE COMMENT: <br /> REQUESTOR'S INFORMATION: <br /> BUSINESS NAME / r .!- ATTENTIONaowe <br /> MAILINGADDRESS 3v PHONE 0/ /!�/./ (A966)0 <br /> CITY STATE ZIP EMAIL v a <br /> C�✓Gi-n Pn� � �St`J.S[� `�° ✓1 P• CI�W .C'v:'►'� <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ REQUESTOR® <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 JOAQLIIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the same time it is provided tome my re sentative. <br /> I <br /> APPLICANT NAME(PLEASE PRINT) c me_S G1 SIGNATURE <br /> (/ <br /> TITLE JZ /�i� JCL TAxID# <br /> rtf' <Ild.'I-,ry 7 <br /> FA#: TyA Nl� OWNER ID#:�VU00'"3 ACCOUNT#: 23 A881GNE0T0: <br /> PRS: 1\ cs ACCOUNTING COMPLETED BY:J DATE: 3 <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV D BY DATE SERVICE REQUEST t INVOICE# <br /> Work Plan 2903 523 $456.00 't ` . y �l )3 I�j s�L�� Iv <br /> 2904 523 $760.00 `l /` 1 I 0 1 <br /> Site Mitigation MFR 2-26-2018 <br />