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SAN JVAQUIN COUNTY ENVIRONMENTAL HEALTH /DEPARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE March 30,2017 SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CWeoMiFOwWERR/s CURREWnroWFMenTrx EHO ❑ <br /> PROPERTY H.M Weinberg PNONE <br /> OWNERNAEE FmST Sr 310-363-7775 <br /> BUSINESS NAME Peloria Paradise Point LLC eHAhowa e99 <br /> oward weinber law.la <br /> OWNERHOMEAODRESS 2775 Via Tejon, Suite 2B ATTExTim:oRCARE OF(DPnww) <br /> CITY Palos Verdes Estates STATE CA LP 90274 <br /> OWNER MAILING ADDRESS 2775 Via Tejon, Suite 213 <br /> MAILNGAwNESSC" Palos Verdes Estates ST"TE CA LP 90274 <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GovmxMExr AGENCY ❑ReanianaLE PARTY OTHER LLC <br /> ❑ ENVIRONMENTAL ❑ EHDLOCALVOLUNTARY RWQCBLEAD- ❑ RWOCB LEAD- El DTSC LEAD [I FED EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 29$9 29$4 <br /> 2950 2953 2960/352613527 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 I( <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES No ❑ <br /> BUNNESSIFAOUW/SrWPRwECT NAME Paradise Point Marina APN: <br /> Sm ADosassIPRoJecTLOCATION 8095 Rio Blanco Road BUSINESS PHONE 209-952-1003 <br /> CITY Stockton STATE CA ZJP 95129 <br /> BOARDOFSUPERVISORDISTRIcT LOCATION CODE Kai KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILRY ADDRESS <br /> MMUNGADORESBCRY STATE LP <br /> SIC OWE COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ATTENTION:wCARE OF(Orr Lama) <br /> MAILING ADDRESS PHONE <br /> Cm STATE ZIP <br /> ACoOUNTADDREw TOamo FEES ANDCHARGEs: OWNER❑ FACILTTYIBUSINESSI[x THIRD PARTY BILLING❑ <br /> BILGING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent, <br /> or Responsible Parry and I acknowledge that all PERMrT FEES,PENALT/ES,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.I 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, I hereby authorize the <br /> release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENYmoNMENTAL <br /> HEALTH DEPARTMENT as soon as it is available and at the same time it is provided tome or my re esentative. <br /> APPUCAMTNAMEIPUSUIEPRINT) Peloria Paradise Point LLC SNRuNRE <br /> TITLE Howard Weinberg, Manager T�i1D' 46-3434584 <br /> FAY: OWNER I00:Owa--0773� ACCOUNT Y: �i -�' AAIIGNEO TO: <br /> PRY: ACCOUmNGCoMPLETED BY: K 7' DATE: <br /> 9-&2015 J <br /> Site Mitigation MFR 29- <br />