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STATECA <br />ZIP z/9 <br />THIRD PARTY BILLIN9kr ACCOUNT ADDRESS To SEND FEES AND CHARGES: FACILITY/BUSINESSO OWN ERD <br />BUSINESS NAME A m <br />F0,S7C/' )1//)('C'/L-'r <br />MAILING ADDRESS [6.e. 60 wo 0 cirei v re /01 <br />f)(7-7- of vino. Car <br />ATTENTION: ORCARe: (OPTIONAL <br />ry / "Ir ir)& <br />PHONE 70 zsi <br />TITLE <br />SAN JvAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 5 A 6/Z-0 17 SHADED AREAS FOR EHD USE <br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD <br />PROPERTY <br />OWNER NAME <br />PHONE <br />7q0- Pa 0-3.5 Y FIRST MI LAST <br />BUSINESS NAME <br />66, rqu,S 7-Or <br />E-MAIL ADDRESS <br />pi )1. Doe-fie., f wi St ar,4 <br />OWNER HOME ADDRESS 3/0 hie.5 7, W 0 7cer ,....<77.e.,...7 ATTENTION: OR CARE OF (OPTIONAL) g di <br />17() er r <br />CITY <br />e <br />TATE ait,,ho rC (,) l/s ZIP <br />OWNER MAILING MAILING ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />,CORPORATION <br /> 0 INDIVIDUAL <br />0 PARTNERSHIP <br /> <br />0 GOVERNMENT AGENCY 0 RESPONSIBLE PARTY <br /> <br />0 OTHER <br />. ENVIRONMENTAL . EHD LOCAL VOLUNTARY ..1S-RWQCB LEAD - <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />RWQCB LEAD - <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />WATER QUALITY (WDR) <br />2965 <br />DTSC LEAD . FED EPA LEAD <br />2959 2954 <br />FACILITY FILE: COMPLETE BUSINESS! SITE/ PROJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES 0 No /13. <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES)a No 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME <br />Ne Vet (k 6r0 vp Ste( t.( P679-/ • 1700/61 Fa/..1 iffy <br />APN: 12/ 1-- 23 00,_ <br />SITE ADDRESS / PROJECT LOCATION 25 00 We .7 _ / BUSINESS PHONE <br />GA v re )) . ‘'7` rel 4? l q -4-- <br />CITY 7 <br />i- 0 ek--7-on <br />(........, A STATE 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 />THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <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 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 JOAQULN COUNTY ENVIRONMENTAL <br />HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my r presentative. <br />APPLICANT NAME (PLEASE PRINT) 0 11 r 42 SIGNATURE 4P-Aii <br /> <br />TAXI" <br />FA #: ,...... <br />1--,41 002-3 2-3-1 <br />OWNER ID #: 0 0002j ,." q 1 ACCOUNT c <br />iii20042-- 87 6 ASSIGNED TO: <br />PR #: <br />Fk6) S-2-1-07L11. 61 <br />ACCOUNTING COMPLETED BY: DATE: 5/36/17 <br />9-3-2015 <br />Site Mitigation MFR 29- <br />Oe -7 7