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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 1011512k SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK /F OWNER IS CURREN/Yr ONFILE WITH EHD <br />PROPERTY <br />OWNER NAME <br />"g1 G-C.X <br />PHONE <br />(Ls-6) Sbo- 2,8 q S FIRST MI LAST <br />BUSINESS NAME A <br />$10-burvt cn ca rlevt tr S Cob? e r aj-on C 1,‘ c • <br />E-MAIL ADDRESS <br />OWNER HOME ADDRESS ATTENTION: ORCARE OF (OPT7ONAL) <br />ilk Sr( g-d IQ t' <br />CITY STATE ZIP PVL 35-6,0 1 <br />OWNER MAILING ADDRESS ? 0 'tx./A. ti.. Z 1 <br />MAILING ADDRESS CITYbe( cutu r STATE A t_ LP is-c,ok <br />1:61CORPORATION <br /> 0 INDIVIDUAL <br /> <br />0 PARTNERSHIP 0 GOVERNMENT AGENCY 0 RESPONSIBLE PARTY <br /> <br />0 OTHER <br />Ig ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />IN EHD LOCAL VOLUNTARY M RWQCB LEAD- a RWQCB LEAD- <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />MI DTSC LEAD M 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 worm? <br />YES RI No 0 <br />YES 0 No 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME <br />1150 1111MS .‘ An# S <br />APN <br />oci 24 -110 - 0 S-0 -0 00 <br />SITE ADDRESS / PROJECT LOCATION <br />Z 3 ci 1 5 £c4 MIL-hr g 8 <br />BUSINESS PHONE <br />(tol) if g 1 13 0 0 <br />Om <br />Linde-Y-1 'T <br />STATE ZIP cA 1St. 36 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE 1 KEY1 , ppilte 1 KEy2 1 <br />MAILING ADDRESS . IF DIFFERENT FROM FACILITY ADDRESS RECEIVE <br /> S. <br />MAILING ADDRESS CITY <br />5 fICC i 911 <br />STATE ZIP <br />SIC CODE COMMENT: Inli(1L3IN CCA-114.1"Y <br />REQUESTOR'S INFORMATION: <br /> <br />014m <br />BUSINESS NAME A I la s HEAL ; TTENTION <br />MAIUNG ADDRESS 2 0 a t c (INN) Can y or\ v ei ..s ...).A ttc 2. 1 0 PHONE 5 10 3 6 , <br /> <br />i 5 z s <br />Cm ( <br />'-)ct n Z a rNi or% <br />STATE c A 211341H 5 ,os Ewa <br />ivtkcv, 41 t \ c .toe ( L.A. 19 i. C,-) c ,v l,e mt. <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER0 II FAciLiTy/BusiNEs41 (—Ecilrc--)---') <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 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 provided to me or my representative. <br />APPLICANT NAME (PLEASE PRINT) IVI tCANt. -?.extA-64-• <br />SIGNATURE <br />G7t0 0 cy'st <br /> <br />FA #: <br /> <br />OWNER ID #:W ()Oz.-471n <br />ACCOUNTING COMPLETED BY: <br />ACCOUNT #: ASSIGNED TO: <br /> <br />DATE: / <br /> <br />IFFTY-113 E .. PE SC FEE INFO AMT REMITTED CHECK# RECY'D BY DATE SERVICE REQUEST4 ' INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$45.6.00 <br />$760.00 1-1-5-- 5350 A----105/2.1 C /2. 00g LI-3* <br />TITLE TAx ID <br />Site Mitigation MFR 2-26-2018