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No Ef YES 1:1 <br />YES No[i] <br />JAYE <br />SIC Coos <br />Mama ADOREM cn <br />Cosorem <br />Ontlei z'P 75-575 <br />ckal 5 v;,9v1 A <br />230 < rH.1-Puivi Pavd4 rCy-f •5) <br />(r <br />CrrY <br />REQUESTOR'S INFORMATI N: <br />BUSINESS NANE <br />/Loma ADORESS <br />STATE 61LI <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 />1-0/101‘ MAI* S 64(614 <br />Bussress/FAcsurr/SrrE/PRoJecT NAME r <br />'40 WO 1,von\P4 (A-41U <br />An ZIP <br />BOARD OF SUPERVISOR Distisor LOCATION Coos Karl KEr2 <br /> <br />MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS P yo <br />APN <br />u I fr. <br />40.1-7 <br />BusNess -1 I <br />Prci— 213+.305 &it ADORES5 I PRcuEcr Locimood <br />Arremom <br />P"3"1 7 ;2041,7 <br />Ewa.5)77.,m;,7(/ ZIP 4 .--cieoi <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE --—U) SHADED AREAS FOR END USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OVINE R IS CURRENTLY ON FILE WITH END <br />Namur <br />OWNER NAME 14° MI5 ;CC4ft <br />P• /1, /7 ...„,_ 401KE <br />9( 0 4 -3 q .'-a i 5 -3 IRS T M/ L4 <br />Busaaess Nue . <br />i <br />', <br />i <br />, rool ,k) --\615 <br />.Q\Amv) <br />EMAIL <br />A137-8-8Kilt, .5 510C et ,ILA w ? v <br />Ovntes ROME ADDRESS ArremoN. °RCN's Or (rnot,w) <br />STATE ZIP <br />O'WHER MAILING ADORESS p , 0 , pliri VID <br />MAILING ADDRESS CITY U1/4.),,.., , ILA A 1 ,IR STATE Zw <br />[=.1 CORPORATION INDIVIDUAL PARINERMRP GovEstoderr AGENCY 0 RESPONSIBLE PARTY <br /> <br />sN/<6THER lYI <br />EHD LOCAL VOLUNTARY <br />CLEANUP <br />2953 <br />1:RWQCB LEAD— <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />RWQCB LEAD — DISC LEAD <br />2959 <br />FED EPA LEAD <br />2954 <br />. ENVIRONMENTAL II • III <br />ASSESSMENT <br />2950 <br />WATER QuAurY (WDR) <br />2965 <br />FACILITY FILE: COMPLETE BUSINESS! SITE/ PROJECT INFORMATION: <br />I Accourir ADOREss To SEND FEES AND CHARGES: OwNERI: FACILITY/BUSINESS CI REQUEST° <br /> <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 reAlts, reports, and other environmental assessment information to SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEP,A,RTML.44—TA. d^"" Xiit is available and at the same time it is proy.)ded t i m rny representative. <br />AppucAirr mum (PLEASE PRINT) E SKII4ATURE S 1 P ? <br />TAX1D# <br /> <br />- .., FA N: <br />Wal)1, i <br />OWNER ID S: <br />1 -12 u _i ACC°11.ff °II: Pre-L±0 L46-19,0 . Aagit3WED TC): <br />PR it: -,,' 4 l 1 ACCOUNTING COMPLETED BY DATE <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE SERVICE REQUEST# INVOICE# <br />2903 <br />2904 <br />523 <br />523 <br />Work Plan \ <br />$456.00 <br />$760.00 .L, - 1 ( i LI 2- -7 I el c---t. •-• 1(1 1 I I <br />TmE 1/44')c,1 It <br />Site Mitigation MFR 2-26-2018