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DATE August 11, 2017 <br />CHECK IF OWNER IS CuRRENTLY ON FILE WITH EHD OWN ER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: <br />ATTENTION: OR CARE OF (OPT/O/WIL) OWNER HOME ADDRESS PO Box 315 <br />BUSINESS NAME TERANISHI IRREVOCABLE ADMINISTRATIVE TRUST <br />E-MAIL ADDRESS <br />SHADED AREAS FOR EHD USE <br />PROPERTY <br />OWNER NAME <br />Sheldon <br />Elks, MI Teranishi LAS <br />PHONE 209-522-4119 <br />SAN JI JIN COUNTY ENVIRONMENTAL HEALTH I /RTM ENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />CITY BODEGA BAY <br /> STATE CA <br /> ziP 94923 <br />OWNER MAILING ADDRESS SAME <br />MAILING ADDRESS CITY <br /> STATE <br /> <br />ZIP <br />0 CORPORATION <br /> <br />0 INDIVIDUAL <br /> <br />0 PARTNERSHIP <br /> <br />0 GOVERNMENT AGENCY IA RESPONSIBLE PARTY <br /> <br />0 OTIIER <br />i ENVIRONMENTAL 0 END LOCAL VOLUNTARY <br />CLEANUP <br />2953 <br />0 RWQCB LEAD- FtWQCB LEAD— <br />ASSESSMENT <br />2950 <br />CORRECTIVE Acnow <br />296013526(3527 <br />WATER QUALITY (ViDR) <br />2965 <br />DISC 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 0 <br />IS THIS AN EXISTING PROJECT LOCATION, BUT ANEW SCOPE OF WORK? YES El No 0 <br />BUSINESSTACILITYiSiTEiPROJECT NABIE FORMER GEORGE'S SERVICE 1 APN: 255-100-39 <br />SITE ADDRESS i PROJECT LOCATION 1680W. DURHAM FERRY ROAD BUSINESS PHONE <br />City TRACY STATE CA ZIP 95376 <br />BOARD OF SUPF_RVISOR DISTRICT I I. LOCATION CODE KEYI 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 />BUSINESS NAME AlTEETTION OR CARE Or (oPrioivAL) <br />MAILING ADDRESS PHOME <br />CITY STATE ZIP <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES' OWNER FACILITY/EUSINESSO THIRD PARTY BILLING 0 I I <br />RIIA.ING AND COMPLIANCE AUKNOWLEDGNIENT: I. the undersiEned Applicant, certify that I AM the Owner, Operator, Authorized Agent, <br />or Responsible Party and I acknowledge that all PERMIT FEES, PEN-ILTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated <br />with this project will be billed to me at the address identified above as the ACCOUAT ADDRESS for this site. I also certify that all <br />information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all <br />applicable Sr JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the <br />undersigned Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby <br />authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN CO ATV <br />ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my rpyesentative. <br />( - TITLE (-) <br />LZ: <br /> <br />TAX ID <br /> <br />APPUCANT NAME (PLEASE PRINT) SHELDON TERANISHI <br /> <br />SIGNATURE <br /> <br />FA •/:376023 70-1 OWNER <br />ID * Odo02-2-1 37— ACCOUNT #: ASSIGNED TO: <br />SR TYPE <br />2903 <br />PE <br />523 l $456.00 <br />ACCOUNTING COMPLETED BY: 02_ <br />ANT REMITTED <br />DATE: <br />DATE SERVICE REQUEST <br />j <br />NVOICEB <br />3760 0e7 Vi31/ <br />PRA: <br />CHEM RECYD BY SC <br />FEE INFO