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THIRD PART/ BILLING] ACCOUNT ADDRESS TO SEND FEES AND CHARGES: FACILITY/BUSINESSO OWNER0 <br />THIRD PARTY BILLING INFO: COMPLETE IF ILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />SS BUSINE NAME <br />MAIUNG ADDRESS ,323-21(;) <br />CrrY <br />I LI vi\1144(\ <br />5\ 4'5 ty,i0/37.3 \IN"( <br />ATTENTION: ORCARE OF (0P770NAL) <br />PHONE •••..5 <br />STATE ( A_ ZIP <br />4-aJtvA4 "6,4 <br />2‘6(c .? <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH E .RTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE I t) / I / )0 i —1 SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD <br />PROPERTY <br />OWNER NAME <br />Nku kp CA Qh \-v‘ PHONE , r , 361, 4,5 1 14 _ q i FIRST MI LAST <br />BUSINESS NAME S ilA 1/4 -1/44 A jty% (;%.\ <br />E-MAIL E-MAIL ADDRESS <br />OWNER HOME ADDRESSLIU *-1", • y <br />it ‘75) (-fl CI' itiO ATTENTION: ORCARE OF (OPTIONAL) <br />CITY fre 140 ._ STATE LA ZIP Clzi s 55 <br />OWNER MAILING ADDRESS lif.:51 <br />f--: \ TZVIA) f4 ' <br />MAILING ADDRESS CITY <br />S \l' K \\>1 \ <br />STATE (..A <br />ZIP qe5 70(6, <br />0 CORPORATION <br /> <br />0 INDIVIDUAL <br /> <br />0 PARTNERSHIP <br /> <br />0 GOVERNMENT AGENCY 0 RESPONSIBLE PARTY <br /> <br />0 OTHER <br />M ENVIRONMENTAL • EHD LOCAL VOLUNTARY <br />CLEANUP <br />2953 <br />154 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 QUALITY (WDR) <br />2965 <br />• • <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 No lA <br />YES .V1 No 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME ustj,k_A _ scivt vel_ APN: I (05.1 s :;.; _ DC/ <br />SITE ADDRESS / PROJECT LOCATION qc,51 G .ek\ 0 orekko 5k, BUSINESS PHONE <br />Crry <br />S .(') 61< 01i STATE ZIP <br />43 <br />' BOARD Of SUPERVISOR DISTRICT LOCATION CODE KEY1 <br />ji <br />Kr/2 <br />MAILING ADDRESS, IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />SIC CODE COMMENT: <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 representativ <br />APPLICANT NAME (PLEASE PRINT) g, SIGNATURE <br />ezo <br /> <br />TITLE <br />1/11 12 11/19 if I /IA 11AV f <br /> <br />TAxiD# <br /> <br />FA#: ..... - 4 <br />MOD,243W <br />OWNER ID titocyz 2_03 ACCOUNT #:vilm_.0.efs--33.7 ASSIGNED TO: <br />PR #: ACCOUNTING COMPLETED BY: 0 <br />/0 <br />DATE: ///3/1 ,_.7 <br />1 ( <br />9-3-2015 <br />Site Mitigation MFR 29-