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Y J(UN I H T E e CU COUNTY dNOMENT HEALTH
<br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM
<br />"MFR"- GREEN FORM
<br />DATE SHADED AREAS FOR EHD USE
<br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER Is CURRENTL VON FILE WITH EHD
<br />OWNER NAME
<br />PRopE RTY 5 ‘"i_ A i i,161 4:4-4./i-/1 C 0 tit 1-
<br />PHONE \
<br />Z'o 9) i f - gas t-iRsy 7 MI LAST
<br />BusIsEss Nun [961 h I c c__ Vio(ks E-MAIL ADDRESS m o, r 1 _
<br />OWNER HOME ADDRESS Lill, NI , 5,_ „I ,) 0 ct,„. v , 1 .,•7 __ f.--2.. re, ,....5,3 0 ATTENTION: ORCARE OF (OPTIONAL)
<br />STATE LP
<br />OWNER MAILING ADDRESS ii 5 20, Ve ( --- kl— /IA :1 e. R..._J
<br />MAILING ADDRESS CITY
<br />5I-C, C I( 1-0 71 9 5 2-0 9
<br />STATE ZIP
<br />El CORPORATION
<br /> INDNIDUAL
<br />
<br />0 PARTNERSHIP .j:IOVEFINMENT AGENCY
<br />
<br />0 RESPONSIBLE PARTY
<br /> 0 CrraEa
<br />jZit,RWQCB LEAD-
<br />CORRECTIVE ACTION
<br />2960/3526/3527
<br />RWQCB LEAD- ENVIRONMENTAL EHD Local. VOLUNTARY DTSC LEAD FED EPA LEAD
<br />ASSESSMENT
<br />2950
<br />CLEANUP
<br />2953
<br />WATER QUALITY (WDR)
<br />2965 2959 2954
<br />FACILITY FILE: COMPLETE BUSINESS! SITE/ PROJECT INFORMATION:
<br />ISTKIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES 0 Ncl...EK-
<br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? yEs Os No 0
<br />BuaiNess/FAcuryISRE/PRoJecT Nmie .
<br />r "- bi, , 147-0rk5 APN:
<br />SITE ADDRESS / PROJECT LOCATION 810 j_____ il,2_ e I r 0 „I suaiNEr ..3)NE 4) m _ 7
<br />an, <7-0 c 4- -roc\ (4 52-0 2-- STATE LP
<br />BOARD OF SUPERVISOR DISTRICT 1 LOCATION Coos I KEY1 1 KEY2
<br />PAAILINO ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS q if # / 5-ci.4,J047,,,14 sr-- 51--_.5-q C /
<br />MAIUNO ADDRESS CITY
<br />)r0 to, 64 (16 zi.i -z__- STATE ZIP
<br />SIC CODE Comm:
<br />THIRD PARTY BILLING INFO: COMPLETE IF BILUNO PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE.
<br />BUSINESS NAME ATTENTION: °ACME OF (OPTIONAL)
<br />
<br />MAILING ADDRESS PHONE
<br />CITY STATE ZIP
<br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: I OWN!‹ FACILOY/BUSINESSO THIRD PARTY BILLINGEI
<br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that! 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 aU 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 COUNIT ENVIRONMENTAL
<br />HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to m or y representativt7
<br />APPUCANT NAME (PLEASE PRINT) /14 ; /71
<br />
<br />SIGNATURE
<br />
<br />TAX ID tt Trn_E 4
<br />Lo\i/SMA'at JO/ 1-944 cr,/,
<br />FA it:to F4Do-R,33gS
<br />°wan to - • , von,z i i, I 4,
<br />AocoUNTOIA 01+3 di, c, ASSIGNED TO:
<br />—
<br />no:
<br />?265-4671('
<br />'ACCOUNTING COMPLETED SY: (jet DATE:
<br />4/7
<br />9-3-2015
<br />Site Mitigation MFR 29-
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