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'\--1116 FAAv (DA (raw J vykt j‘ ' <br />FtVli( Pr. 550 <br />crry <br />Li411‘41,0\ revik <br />ATTENTION: ORCARE OF (OPTIONAL) Au° vtiA Av jer <br />PHONE 530 _.)(,) <br />STATE (4 ZIP 9 <br />BUSINESS NAME <br />MAILING ADDRESS 33 3c, <br />I ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br /> <br />OWNERD <br /> <br />FACiLITY/BUSINESSO <br /> <br />THIRD PARTY BILLINagf <br />SAN J..--QUIN COUNTY ENVIRONMENTAL HEALTH _ /ARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 9 - 12- --1 .1 SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD RI <br />PROPERTY <br />OWNER NAME <br />c IN 4 1310.(aS PHONE <br />o CI- 5i 3 - 3cijo FIRST MI LAST <br />BUSINESS NAME E-MAIL„ADDREpS <br />Kli (.4 lityni 5 12 ey a 1200, Uyvi <br />OWNER HOME ADDRESS , --1 1 q R u.61.11:ivi udimi D ilv.4 ATTENTION: OR CARE OF (OPTIONAL) <br />Cm 5 itl 11,v\ STATE ( 4 ZIP ci 5 20 L) <br />OWNER MAILING ADDRESS ci i q 1 <br />rt V A Li) VG( I (At Dfo-e <br />MAILING ADDRESS CITY 5' 6<icivi. STATE 0 ZIP e15 74, <br />0 CORPORATION 1:2fINDIVIDUAL 0 PARTNERSHIP 0 GOVERNMENT AGENCY 0 RESPONSIBLE PARTY 0 OTHER <br />. ENVIRONMENTAL M EHD LOCAL VOLUNTARY Ii RWQCB LEAD- M RWQCB LEAD- <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />M 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? <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? <br />YES 0 <br />YES 17,A <br />No -15h <br />No 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME F.0 /NM Stlitl..0 ifiALVn APN: 1 0 _D(00 1 ' - r L <br />SITE ADDRESS / PROJECT LOCATION A 1 -1 , ,, .4.- <br />"Cit) TV \ 1-.-14 /10 \li.. <br /> <br />BUSINESS PHONE <br />061-. <br />/1... < <br />i <br /> ••• -. ..• <br /> <br />(7( -i - 51/3 6, CIT., 5 6(Ac\64\ cl STATE ZIP 7 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE Keil Kra <br />MAILING ADDRESS, IF DIFFERENT FROM FACIUTY 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 JOAQUIN COUNTY ENVIRONMENTAL <br />HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my repre tativ . <br />APPLICANT NAME (PLEASE PRINT) 5 4 reJV S ?Al TI/t1 SIGNATURE a <br />TITLE A. TAX ID # 33-acs za, <br />FA #: ..._,.., <br />1-"A e2W \ 53(e I <br />OWNER ID #: Ouk7o 2 1,51D ACCOUNT # <br />A `71-30 2- <br />: j , <br />te_06, I <br />ASSIGNED TO: <br />PR #: <br />?(D3-4OF'S1 <br />ACCOUNTING COMPLETED BY: I <br />/Pa <br />DATE: /0/.2.6/1,7 <br />9-3-2015 <br />Ad 1 3 51. V 3 As, reg L -3( 1,017/1 1 Site Mitigation MFR 29-