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REQUESTOR'S INFORrTION: <br />*A) FI(lUillnA <br />333) ,oic4.(4/1 p. <br />-1 <br />Muusa ADORE88 <br />Cm <br />Bosoms NAME <br />Bun- s 41 4k5 ./,1-6 <br />ATTemoN $coK-- 6i-411 <br />ikvix () STATE ZIP (15-0 PH°NE 1L )--b7k- )4062 <br />SAN JOA AN COUNTY ENVIRONMENTAL HEALTH DE. ITMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"M F R"- GREEN FORM <br />DATE .(3 — d•O t— <br />SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD <br />PRoporry <br />OWNER NAME <br />c) ilA 0),(\b•Y\ CelitIoroiliw\ PHONE <br />Act-Y51-cilit3 , FIRST I MI LAST <br />Buswes Nue iii/\ Ozif‘ _ivk (orip;vtivt <br />OWNER HONE ADDRESS <br />' if 55 ku\ ardi OF (OPTIONAL) Aia u dem Pi-eh leil Arremon. ORCNIC <br />Cm <br />-FrOik4; <br />STATE (1 I ZIP Li 555 <br />J 1 /4-e0 (741(CA (E , j j OWNER Wawa Atoms .t.'2 1 . -.")\' , <br />muuno ADORE= CITY <br />--./-1 U1114)W <br />STATE ZIP Ci v/5-j• 5 <br />i,€::01tPORATION 0 INDIVIDUAL El PARTNERENW 0 Downtown Mawr 0 Ftesponame PARTY 0 OTHER <br />M ENVIRONMENTAL M EHD LOCAL VOLUNTARY <br />CLEANUP <br />2953 <br />t RWQCB LEAD- <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />RWQCB LEAD- DTSC LEAD <br />2959 <br />FED EPA LEAD <br />2954 ASSESSMENT <br />2950 <br />WATER QuAuri (WDR) <br />2965 <br />IN MI <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 No a <br />YES Ell No 0 <br />BuseNoss/FAciurdSire/PRomm NAME C.14 uN ivy( 44-2. APN <br />SHE ADDRE88 / PROJECT LOCATION -30 --1 50--\--N \ -\ D ro,clit, St\ceif <br />BUSINESS PRONE <br /> <br />effy _VoutOti\I\ STATIC) ZIP 1 590, <br />BOARD OP SueerimettDeamicT I I LOCATION CODE I I''tt I I'ed II <br />e----? MAIUNG Aoonne , w pompon mom FAciurmooness LJ 3(44) ,, • ci vti _A-55-1u/k <br />MouuNo ADOREB8Crry <br />-F-MV14;v14 <br />STATE (A_ LP <br />SIC COOE Leomeirr: <br />I ACCOUNT ADORE88 To SEND FEES AND CHARGES: OWNERD <br /> <br />FACILITY/BUSINESSE REQUESTOR4 <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 <br />information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all <br />applicable SAN 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 COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me o y epresentative. <br />APPUCANT Kum (PLEAsE PRocr) 5 kiekkl) rtp/wwiti c SIGNATURE Lf4 <br />P/Ibfii iflAy <br />T AX ID* % <br />FA*: 5464,:a(131_ ) OWNER 10 It: 0 Ukozz yKS I ACCOUIITO: Mexyt..5-437 AISIGNED TO: <br />" <br />Pitt OS42-3(pc <br />ACCOUNTING COMPLETED BY: ' DATE: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHEM/ RECYD BY DATE SERVICE REQUEST# INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 <br />>-' <br />_tIS4 1 1— )( i z_zi is . t -c t. 1 € c ' ' <br />Site Mitigation MFR 2-26-2018