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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEF..iTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 2/22/1B SHADED AREAS FOR RHO USE <br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CLIRI?ENTLY ON FILE WITH END <br />PROPERTY <br />OWNER NAME <br />LAi h n P nthur PHONE <br />11 .1S-0 — 9 2 01 FIRST MI LAST <br />BUSINESS NAME S i .eVy a. chkivii co-k C OM <br />E-MAIL ADDRESS <br />OWNER HOME ADDRESS <br />S- <br />ATTENTION: ORCARE OF (OPTIONAL) <br />CITY <br />3Z/Zrrfr- V'eAn 0 <br />STATE ZIP • <br />I <br />OWNER MAILING ADDRESS S CUlik..e._ <br />MAILING ADDRESS CITY STATE ZIP <br />CORPORATION INDIVIDUAL PARTNERSHIP 0 GOVERNMENT AGENCY 0 RESPONSIBLE PARTY 0 OTHER <br />ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />Il ERD LOCAL VOLUNTARY IIII RWOCB LEAD - III RIA/QCB LEAD - El DTSC LEAD <br />2959 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />III FED EPA LEAD <br />2954 <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 WORN? <br />YES El tlo g <br />YES CZ NO 0 <br />e) BUSINESS/FACILITY/SITE/PROJECT NAME Thaick <br />C o \A prak 6 - APN: 1 -::: 1 _ 2 _ s-3 <br />SITE ADDRESS / PROJECT LOCATION two TridusfrickA 0 I" • BUSINESS PHONE z o q _. cig 3- 'i,-. 2 't <br />CITY <br /> <br />5t-t0}1 <br />STATtA ZIP <br />BOARD OF SUPERVISOR DISTRICT ' LOCATION CODE I I KEY1 I I KEY2 I <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 144 11 -.11/ A- e <br />MAILING ADDRESS • ) /,.(4 <br />ATTENTION: ORCARE OF (OPTIONAL) <br />7;) - L/CV-7 <br />CITY <br />-(4 C' I/ / fl r/C <br />STATE <br />Cr <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br /> <br />OVVNER0 <br /> <br />FACILITY/BUSINESSD <br /> <br />THIRD PARTY BILLINGa <br />BILLING AND COMPLIANCE AcRNOWiEDcm ENT: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, or <br />Responsible Party and I acknowledge that all PEIWIT FEES, PENALTIES, ENFORCEAIENT CHARGES and/or HOURLY CHARGES associated with <br />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 pr sentative. <br />APPLICANT NAME (PLEASE PRINT) /_ a <br /> <br />SIGNATURE <br />TITLE _ i 17; 1--)e'e TAX ID # <br /> <br />FA #. OWNER ID ii: ACCOUNT #: ASSIGNED TO: <br />PR fk ACCOUNTING COMPLETED BY: DATE: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD By DATE SERVICE REQUESTit INVOICE11 <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 <br />6 <br />Site Mitigation MFR 29- XXX 8-1-2017