COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION MASTER FILE RECORD INFORMATION FORM "MFR"- GREEN FORM DATE C77 2 1 / I 7 SHADED AREAS FOR END USE OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD IN PROPERTY OWNER NAME Sv--P, mut- y PHONE '2-cc1 3 3 3 6 -7 P -,L, FIRST MI LAS1 BUSINESS NAME (-2, Ty 0 t.:-." 1.-0D 1 E-MAIL ADDRESS CS‘"),eriLesyCd (--o13) , 6.-70V OWNER HOME ADDRESS 2 1 i )6/ pi p,..) c iTIR G., c --r ATTENTION: OR CARE OF (OPTIONAL) CITY L-oD l STATE A ZIP 9 5 zzi, 0 OWNER MAILING ADDRESS MAILING ADDRESS CITY STATE ZIP ILI CORPORATION 111 INDIVIDUAL E PARTNERSHIP JX1GOVERNMENT AGENCY El RESPONSIBLE PARTY El OTHER . ENVIRONMENTAL IIII EHD LOCAL VOLUNTARY RWQCB LEAD— X RWQCB LEAD — WATER QUALITY (WDR) 2965 EI DISC LEAD 2959 ASSESSMENT 2950 CLEANUP 2953 CORRECTIVE ACTION 2960/3526/3527 FED EPA LEAD 2954 FACILITY FILE: COMPLETE BUSINESS! SITE/ PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES D No ts. IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES rsc. No 111 BUSINESSIFACILITY/SDE/PROJECT NAME APN: C efskR.Al.. e LA.) 01 E /1Y1 ill) R.,..) 01G PC / TLE 1k) hi ,s4 ' i•J/A SZR CET R/ti v SUE ADDRESS i PROJECT LOCATION 1 5,3 .1-tURCt.-1. S-1 BUSINESS PHONE Orry L. 0 i. 1 STATE ZIP fly 65 5 2. 40 BOARD OF SUPERVISOR DISTRICT 1 1 LOCATION CODE I I Keil I I Kea I MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS LATY of' I-01)1 euot-i, (,,, ukt-t DCP"r , 2:24 kJ ()I N& Sr MAILING ADDRESS CITY L ot-) \ STATE ZIP 1 cz,ero CA SIG CODE COMMENT: THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME ATTENTION: ORCARE OE (OPTIONAL) MAILJNG ADDRESS PHONE STATE ZIP ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNERtit FACILITY/BUSINESSD THIRD PARTY BILLINGEI BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, or Responsible Party and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated 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 provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL 111.AI:111 DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. APPLICANT NAME (PLEASE PRINT) L(..143Lz _S R TrTLE c_ Rc-c-rok. SIGNATURE TAX ID# FA G: F40024246 OWNER lo #: 0 tv Do 2.2_s-0 ACCOUNT II: /4 Ra),_/6-2 3 r ASSIGNED TO: PR G: ?Rx7,542 7 , i ACCOUNTING COMPLETED sY: ( DATE: 77257 7 SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# I INVOICE# Work Plan 2903 2904 523 523 $456.00 $760.00 4 -1,:> dj, ..A.# i LA .) IL:A.X.) t Site Mitigation MFR 29- XXX 8-1-2017