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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 />ENVIRONNIENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is p 'tied to me or my representative. <br />APPLICANT NAME (PLEASE PRINT) ( ) ; SIGNATIIRE. <br />TITLE 1-044,.. 6'1 1 ,1 ylit I TAX ID # <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 2-112- / 1 g. SHADED AREAS FOR END USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY' ON FILE WITH END LII <br />PROPERTY <br />OWNER NAME <br />L ki y\ n YAnd9-r. PHONE <br />11 — - 1 Zo I FtF51- Ml LA , r <br />BUSINESS NAME S 1 orv a cifru jot, extA Co imp0-4A-1 E-MAIL ADDRESS <br />OWNER NOME ADDRESS I 11„ Z., t- Dou ic..„ LJ\ j ATTENTION: ORCARE OF (0PTIONAL) <br />CITY titir \ 0 STATE N \J ZIP 9, 1 si I <br />OWNER MAILING ADDRESS S CUll‘c <br />MAIUNG ADDRESS CITY STATE ZIP <br />0 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 GOVERNMENT AGENCY 0 RESPONSIBLE PARTY 0 OTHER <br />kr ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />E EHD LOCAL VOLUNTARY MI RWQCB LEAD - . RWQCB LEAD - <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />M DISC LEAD . FED EPA LEAD <br />2959 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 WORK? <br />YES D No g <br />YES vir No 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME Thafatex- Co vvipart u 6/ c A. APN: n 1 _ 2 0 _ c5 <br />SITE ADDRESS / PRoJEcT LocATiON / 01 0 <br />rY1 A <br /> , rs,fri ea w „..,..., I <br />J- IAA-J Y . <br />BusiNEsspHoNE z 09 _ 1 q 3- <br />Crry S -to ct_to r STATiA ZIP 9 s zo 0 c v._ <br />BOARD OF SUPERVISOR DISTRICT I LOCATION CODE , KErl I I KEy2 <br />MAILING ADDRESS, IF DIFFERENT FROM FACIUTY ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />SIG CODE COMMENT: <br />THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />BUSINESS NAME <br />C. IL' V 771- Y1 <br />ATTENTION: ORCARE OF (OPTIONAL) <br />MAILING ADDRESS C, <br />CL; S 1/1 th <br /> <br />PHONE _ <br /> <br />Sot c , ryi ?tile) <br /> STATE c4 ZIP (71,5 <br />7 c' <br /> <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: <br /> <br />OWNER': <br /> <br />FACILITY/BUSINESSEI <br /> <br />THIRD PARTY BILLING% <br /> <br />FA #: , OWNER ID #: I ACCOUNT #: ASSIGNED TO: <br />PR #: ACCOUNTING COMPLETED BY: DATE: 1 <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REOLIEST# INVOICE# <br />Work Plan <br />1 <br />2903 <br />2904 <br />523 <br />523 <br />$390.00 <br />$650.00 <br />9-3-2015Site Mitigation MFR 29- XXX 6-2-2017