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0 GOVERNMENT AGENCY ZRESPONSIBLE PARTY E INDIVIDUAL 0 PARTNERSHIP 0 OTHER CORPORATION <br />ID FED EPA LEAD <br />2954 <br />ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />o EHD LOCAL VOLUNTARY <br />CLEANUP <br />2953 <br />RWQCB LEAD - <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />El RWQCB LEAD- <br />WATER QUALITY (WDR) <br />2965 <br />El DTSC LEAD <br />2959 <br />THIRD PARTY BILLING': ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNERX FACILITY/BUSINESS:I <br />ATTENTION: ORCARE OF (OPTIONAL) BUSINESS NAME <br />MAILING ADDRESS PHONE <br />ZIP STATE <br />RECVD BY CHECK# <br />L- X C30 d' <br />53 uggg <br />SR TYPE F SC FEE INFO <br />Work Plan <br />E., <br />2904 <br />523 523 <br />$41-7-4'66 <br />$64,57e6 1(,i) <br />AMT REMITTED <br />4 LIC17 <br />SERVICE REQUESA DATE INVOICE# <br />6/1 <br />SAN Jo • IIN COUNTY ENVIRONMENTAL HEALTH rs PARTMENT <br />SITE MITIG., i ION MASTER FILE RECORD INFOK _.ATION FORM Me 0 3 Lk <br />"MFR"- GREEN FORM <br />DATE %--2--- 1 /- : WEICRIAtbha. <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY* ON FILE WITH EFI'D t,4 <br />PROPERTY <br />OWNER NAME <br />PHONE <br />$17S--1 4 2 -11977 FIRST MI LAST <br />BUSINESS NAME E-MAIL <br />-ori v4I-do K-orlcrel-- 1414-rix-trw.t,ur-A- cov,10.4,ti c1A-eve eni <br />ADDRESS <br />DC-pArCcri e'ctkOV(2,9 Ni •C <br />OWNER HOME ADDRESS ATTENTION: ORCARE OF (OPTIONAL) <br />CITY STATE ZIP <br />OWNER MAILING ADDRESS <br />(00 0 k ZoIA.A.r.-ii01,41— Gpv..4+oir-i P--f) . <br />MAILING ADDRESS CITY STATE <br />5/20N-1 9--kt-4-0 r-I ZIP 1‘..1 s_.0 3 <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 .2f <br />Is THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES k No 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME APN: <br />FlAPPN.OL- ClftWitt") ctIMN Oirs-i VI" q Le Oct( 12-3 - c)60 -2-1 <br />SITE ADDRESS/PROJECT LOCATION <br />)-I 03 cot/I-m(4- e_Li.te5 61-v-0 . <br />BUSINESS PHONE ('IA <br />CITY <br />4rD&WrilINJ <br />STATE ZIP <br />CA-- <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE Keel KEY2 <br />MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS crre 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 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 Owner, <br />Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby authorize the release of <br />any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representativ <br />APPLICANT NAME (PLEASE PRINT) c‘ACAVO i•J cv pj& SIGNATURE <br />f Sve-covte,s- CuviSuvri w6-igeavicts)dp# <br />L. <br />TITLE <br />FA #: r4ina24/ K3 OWNER ID #: OR) 00227 // ACCOUNT #: itie(..:),_i_Lmi,/, ASSIGNED TO: <br />PR #: pleos.„{;2 107 ACCOUNTING COMPLETED BY: DATE: 8•- i 7 <br />Site Mitigation MFR 29- XXX 6-12-2017