FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

SAN JISAQUIN COUNTY ENVIRONMENTAL HEALTH DOARTMENT SITE MITIGATION MASTER FILE RECORD INFORMATION FORM "MFR"-GREEN FORM DATE Mt..fG� L_ ( ,'_. - SHADED AREAS FOR EHD USE OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER is CURRENTLYONFILEwim EHD PROPERTY I. r' F PHONE rU✓* �o.. - 72 OW NER NAME FIRST S Z 1,2?(0 BUSINESS NAME �•7 1 y _ E-MAIL ADDRESS 1�.xxr•(S.l �R�x ��.sa�� .�c�C 4.F�+i1� �c^erv� c,�v .�J OWNER HOME ADDRESS ATTENTION:ORCARE OF(OPTIONAL) y, I ` 1 OL 1„Z 0 �!��Ui CITYLG, • ! � STAT! LP f CiA S 3'2Ca OWNER MAILING ADDRESS MAILING ADDRESS CITY .. t STATE vCORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD- RWQCB LEAD- [:1 DTSC LEAD El FED EPA LEAD ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2859 2EP 2950 2953 29601352613527 2965 954 FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES (� NO ❑ Bus INESSIFACILIT'tSREIPROJECT NAME APN: G%v% Z057-150111 SITE ADDRESS I PROJECT LOCATION BUSINESS PHONE l U t o - Cm J Fir Cu\t” STATE ZIP -7 cr"A• S 3Z0 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEW KIYZ MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS 5,1�-fit MAILING ADDRESS CITY STATE zip -- SIC CODE COMMENT: THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME ATTENTION:ORCARE OF(OPTIONAL) MAILING ADDRESS PHONE CITY STATE ZIP ACCOUNT ADDRESS TO SEND FEES AND CHARGES: Ch THIRD PARTY BILLING❑ BII.LING AND % }'S It I am the Owner, Operator,Authorized Agent, or Responsible Party and I acknowledge that all PERA X-1CHARGESand/or HOURLY CHARGES associated with this project will be billed to me at the address ides s for this site.I also certify that all information provided on this application is true and correct; and t r� 1 I -formed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STAND, /��./D / l/ aws and REGULATIONS. As the undersigned Owner, Operator,Authorized Agent, or Responsible Pal 111 C,Ck:�l l -r facility/site address, I hereby authorize the release of any and all results, reports, and other en to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at t . ..iy representative. \ APPLICANT NAME(PLEASE PRINT) EZC.,c�(� N O�O` SIGNATURE a TITLE TAX IDS FA lY: rA(y_)1;SS OWNER ID1111: � A000YNr M:A/zcci,�,59JASSIGNED TO: PR E: / ACCOUNTING COMPLETED BY: DATE: "111.2-17 —! . 7 9-3-2015 Site Mitigation MFR 29-