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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION MASTER FILE RECORD INFORMATION FORM "MFR"-GREEN FORM DATE SHADED AREAS FOR EHD USE OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER ISCURRENTLYONFILEWITH EHD El PROPERTY PHONE OWNER NAME FIRST MI LAST BUSINESS NAME E-MAIL ADDRESS OWNER HOME ADDRESS ATTENTION:ORCARE OF(OPTIONAL) CITY STATE zip OWNER MAILING ADDRESS MAILING ADDRESS CITY STATE zip ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD— ❑RWQCB LEAD— ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) ❑ DTSC LEAD FED EPA LEAD 2959 2954 2950 2953 2960/3526/3527 2965 FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES Q No ❑ BUSINESS/FACILITY/SITE/PROJECT NAME APN SITE ADDRESS/PROJECT LOCATION BUSINESS PHONE CITY STATE zip BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS MAILING ADDRESS CITY STATE zip SIC CODE I COMMENT: REQUESTOR'S INFORMATION: BUSINESS NAME ATTENTION MAILING ADDRESS PHONE CITY STATE ZIP EMAIL ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ REQUESTORM BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant, certify that I am the Owner, Operator,Authorized Agent, or Responsible Party and I acknowledge that all PERMIT FEES,PENALTIES,ENFoRcEMENT CHARGES and/or HouRLY CHARGES associated 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 information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner, Operator,Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. APPLICANT NAME(PLEASE PRINT) SIGNATURE TITLE TAX ID# FA#: OWNER ID#: ACCOUNT#: ASSIGNED TO: PR#: ACCOUNTING COMPLETED BY: DATE: ESRE' PE SC FEEINFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# 2903 523 $456.00 2904 523 $760.00 Site Mitigation MFR 2-26-2018