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SAN JO, AN COUNTY ENVIRONMENTAL HEALTH DORTMENT
<br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM
<br />"MFR"- GREEN FORM
<br />DATE 14_ Li _).0 1 . SHADED AREAS FOR EHD USE
<br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER Is CURRENTLY ON FILE WITH EHD E
<br />PROPERTY
<br />OWNER NAME
<br />\AAL'iclulwk x tt.i A) ).\.,, (_. I ( Or iC14;)6Llif 5 PHONE
<br />i -+ . 3L' )5 17 IRS ) MI LAST
<br />BUSINESS NAME tUiti TCIVI,LI GilliCik- E-MAIL ADDRESS
<br />Id (c1
<br />OWNER HOME ADDRESS ATTENTION: ORCARE OF (OPTIONAL)
<br />CCt - 1 K(44 , 'v /f _5
<br />CITY STATE ZIP
<br />OWNER MAILING ADDRESS 1-3, 0 ,
<br />SWUNG ADDRESS CITY STATE CI ZIP ci55,,j
<br />9 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 GOVERNMENT AGENCY 0 RESPONSIBLE PARTY ttI OTHER NI,4)
<br />M ENVIRONMENTAL M EHD LOCAL VOLUNTARY
<br />C
<br />RWQCB LEAD -
<br />RECTNE ACTION
<br />2960/3526/3527
<br />RWQCB LEAD -
<br />DTSC LEAD
<br />2959
<br />FED EPA LEAD
<br />2954
<br />ASSESSMENT
<br />2950
<br />CLEANUP
<br />2953
<br />WATER QUALITY (WDR)
<br />2965
<br />• M
<br />FACILITY FILE: COMPLETE BUSINESS! SITE/ PROJECT INFORMATION:
<br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES 0 NO 11,1
<br />IS TI-US AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES t4 NO 0
<br />BUSINESS/FACILITY/SITE/PROJECT NAME "4".' ,-tr ,fikiA Kutt,N-U S "Ct,l-li, V\ APN:
<br />77_
<br />q qo _02 -7
<br />SITE ADDRESS / PROJECT LOCATION \ _. 7 0 i , ,, H
<br />
<br />i ( -a ivvoo Lavl_
<br />BUSINESS PHONV-
<br />ou.k, 0,-.4,,..44 Ic-f )
<br />Orr(
<br />S Z' '1," \
<br />STATELA ZIP 51.,zo 9
<br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE _ KM Kea
<br />MAIUNG ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS p. / \ ‘ L) -
<br />(3 (lb)
<br />MAIUNG ADDRESS CITY
<br />'\J ) U L LJ b/i,iy_ STATEL4 ZIP
<br />9'
<br />5 25?
<br />SIC CODE COMMENT:
<br />THIRD PARTY BILLING INFO COMPLETE IF Bi ING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE.
<br />BUSINESS NAME EvItio\A 440,)
<br />ATTENTION: ORCARE OF (OPTIONAL)
<br />PHONE 530-676-2a z MAIUNG ADDRESS
<br />LP Y5b3z
<br />I ACCOUNT ADDRESS To SEND FEES AND CHARGES:
<br />
<br />OWNERO
<br />
<br />FACILITY/BUSINESSO THIRD PARTY BILLING]
<br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1, 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 />ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is proded to me o my representative.
<br />APPLICANT NAME (PLEASE PRINT) S d/Ty.
<br />SIGNATURE
<br />TITLE
<br />FAN: 47--7400 2/".. . ,, ,..oi , OWNER ID A: ;:)/VA,r) 2,3267 ACCOUNT S: -7,..? z2,/,.., ASSIGNED TO:
<br />PR S: ?kos-,....F., 7 A ACCOUNTING COMPLETED BY: DATE:
<br />SR TYPE TYPE PE SC FEE INFO AMT REMITTED CHECK# RECY'D BY DATE SERVICE REQUEST# INVOICE#
<br />Work Plan 2903
<br />2904
<br />523
<br />523
<br />$390.00
<br />$650.00
<br />9-3-2015Site Mitigation MFR 29- XXX 6-2-2017
<br />STATE
<br />cd1 ifory/1 e '11.1q/
<br />TAX IDS '
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