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El INDIVIDUAL 0 PARTNERSHIP 0 GOVERNMENT AGENCY 0 RESPONSIBLE PARTY 0 CORPORATION 0 OTHER <br />0 DTSC LEAD <br />2959 <br />El FED EPA LEAD <br />2954 <br />12) ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />RWQCB LEAD- <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />RWQCB LEAD— <br />WATER QUALITY (WDR) <br />2965 <br />EHD LOCAL VOLUNTARY <br />CLEANUP <br />2953 <br />ATTENTION: OR CARE OF (OPTKRIAL) BUSINESS NAME <br />MAILING ADDRESS PHONE <br />CITY STATE ZIP <br />SITE MITluATION MASTER FILE RECORD INFORmATION FORM <br />"MFR"- GREEN FORM <br />DATE <br /> 2-17-17 <br />OWNER FILE COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: <br />SHADED AREAS FOR EHD USE <br />CHECK IF OWNER IS CURRENTLY ON FILE WITH END <br />PROPERTY <br />OWNER NAME <br />Nathaniel Papadakis PHONE <br />206.779.4877 FIRST Ml LAST <br />BUSINESS NAME E-MAIL ADDRESS <br />nathanielq.papadakishome.com <br />OWNER HOME ADDRESS <br />2502 27th Ave ATTENTION: ORCARE OF (OPTKMAL) W <br />Cm STATE ZIP Seattle WA 98199 <br />OWNER MAILING ADDRESS <br />MAIUNG ADDRESS COY STATE ZIP <br />=ACILITY 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 RI No 0 <br />YES 0 NO 1:2 <br />BUSINESSWACILITY/SITEIPROJECT NAME APN:235-171-03 <br />SITE ADDRESS I PROJECT LOCATION IS East I I th Street <br />BUSINESS PHONE NA <br />CRY <br />Tracy STATE ZIP <br />CA <br />BOARD Of SUPERVISOR DISTRICT I 1 LOCATION CODE 1 j KEY1 I 1 Keil 1 <br />MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />SIC CODE COMMENT: <br />NI RD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER° FACILITY/BUSINESSe THIRD PARTY BILLING° <br />3ILLINC AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, <br />a. Responsible Pam and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated <br />vith 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 />irovided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN <br />10AQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned <br />)wner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby authorize the <br />elease of any and all results, reports, and other environmental assessment information to SAN S. • . • UIN COUNTY ENVIRONMENTAL <br />-IEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my r <br />APPLICANT NAME (PLEASE PRINT) Nathaniell'apadakis SIGNATURE <br />- <br />.014 <br /> <br />TITLE <br /> <br />TAX ID # <br /> <br /> <br />FA #: <br />1Aoo238-7.2- <br />PR #: <br />fieDLS- / 43-1- <br /> <br />OWNER IOU: I/002.2430+ ACCOUNT LA izoot--/-7z) <br />ASSIGNED TO: <br /> <br />ACCOUNTING COMPLETED BY: <br /> <br />DATE <br />