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BUSINESS NAME <br />MAILING ADDRESS <br />f a /4 ATTENTION: OR CARE OF (OPTIONAL) <br /> <br />PHONE -5,--7/)/ (/ ----/ Utz I / ( <br />Crre 13—c. Kn en./ STATE c <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br /> <br />OWNERD <br /> <br />FACILITYIBUSINESS0 <br /> <br />THIRD PARTY BILLING/RI <br />SAN Jc. JIN COUNTY ENVIRONMENTAL HEALTH F RTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 2/22/18 SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH E HD <br />PROPERTY <br />OWNER NAME <br />L YIN V \ ‘10 nctiLir <br />PHONE <br />FIRST MI LAST 11c -- 2S0 -92 01 <br />BUSINESS NAME <br />£k I C • P. a . . . A . A . i E-MAIL ADDRESS <br />OWNER HOME ADDRESS 19- 2.....S-- pc0J t,' LK) ATTENTION: OR CARE OF (OPTIONAL) <br />Orr <br />:1Ziagfr 19--elt(t 6 <br />STATE N\I ZIP 3.--orl Si / <br />OWNER MAILING ADDRESS S <br />MAILING ADDRESS ADDRESS CITY STATE <br />.RECFIVEll <br />0 CORPORATION <br /> 0 INDIVIDUAL <br /> 0 PARTNERSHIP <br /> <br />GOVERNMENT AGENCY 0 RESPONSIBLE PARTY <br /> 0 OTHER <br />XENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />EHD LOCAL VOLUNTARY IM RWQCB LEAD - RWQCB LEAD - ttti 1 3 CUM <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 ENV <br />E DTSC LEAD FED EPA LEAD <br /> <br />IROAWNTAL 2954 HEALTH: <br />FACILITY FILE: COMPLETE BUSINESS! SITE/ PROJECT INFORMATION: <br /> DEPARTMENT <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 g <br />YES ar No 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME Thaideuf (ow 1 pcaN 6(._ eA APN: 11,1 2 V) S-3 <br />SITE ADDRESS / PROJECT LOCATION 10 i 0 Tro d s fri co. or. BUSINESS PHONE <br />Z0q - '7C 3-12/? C. s t_o cic tal STATtA ZIP %-2 0 (a <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE 1 , KEY1 1 Kea <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 />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, or <br />Responsible Party and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or /Muni CHARGES associated with <br />this project vill 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 rpy-repr sentative. <br />APPLICANT NAME (PLEASE PRINT) L. el I) SIGNATURE ,\ <br />z /./ A-) <br />J- iq hz( <br />FA #: rA0.0,,,,, 1 OWNER ID #: 0(A)00.7 6, ... ACCOUNT #: 400.15735- ASSIGNED TO: <br />PR #: AUSZ+3-5-gE 0 ACCOUNTING COMPLETED BY: 7 0 ozi <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# REM BY DATE SERVICE REQUEST # INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 ) )-2.:17_ L --4, , - - I , <br />Site Mitigation MFR 29- XXX 8-1-2017 <br />TITLE TAX ID # <br />