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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />IIMFR"- GREEN FORM <br />DATE <br />❑ EHD LOCAL VOLUNTARY <br />❑ RWQCB LEAD — <br />SHADED AREAS FOR END USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: <br />CNEcrrrFOwNERisCueREArrcvovF&EwrH EHD <br />PROPERTY <br />OWNER NAME <br />PHILLIPS <br />CORRECTIVE ACTION <br />JOHN <br />2959 <br />PHONE <br />(209)944-0909 <br />/R57 <br />2953 <br />LAST <br />2965 <br />BUSINESS NAME <br />zip <br />E-MAIL ADDRESS <br />OWNER HOME ADDRESS ATTENTION: ORCARE <br />OF (OPTIONAL) <br />CITY <br />STATE ZJP <br />OWNER MAILING ADDRESS 1133 BRISTOL AVENUE <br />MAILING ADDRESS CRY STOCKTON <br />STATE CA LP 95204 <br />❑ CORPORATION ® INDIVIDUAL ❑ PARTNERSHIP ❑ GOVERNMENT AGENCY <br />❑ RESPONSIBLE PARTY ❑ OTHER <br />® ENVIRONMENTAL <br />❑ EHD LOCAL VOLUNTARY <br />❑ RWQCB LEAD — <br />❑ RWQCB LEAD — <br />❑ DTSC LEAD <br />❑ FED EPA LEAD <br />ASSESSMENT <br />CLEANUP <br />CORRECTIVE ACTION <br />WATER QUALITY (WDR) <br />2959 <br />2954 <br />2950 <br />2953 <br />29601352613527 <br />2965 <br />STATE <br />zip <br />FACILITY FILE: COMPLETE BUSINESS I SITEI PROJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES N <br />No Ki <br />No ❑ <br />BUSINEss1FACILnVISREIPR0JECTNAME PHILLIPS PROPERTY <br />APN: <br />163-260-22 & -35 <br />SITE ADDRESS I PRojECT LOCATION 825 NAVY DRIVE & 1137 SOUTH STOCKTON ST, STOCKTON <br />BUSINESSPHONE (209) 944-0909 <br />TTY STOCKTON <br />STATE CA ZIP 95206 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 <br />KEY2 <br />MAILING ADDRESS, IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS CITY <br />STATE <br />zip <br />SIC CODE <br />COMMENT: <br />THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />BUSINESS NAME ADVANCED GEOENVIRONMENTAL, INC. ATTENTION: OR CARE OF (OPTIONAL) <br />MAILINOADDRESS 837 SHAW ROAD PHONE (800) 511-9300 <br />CRY STOCKTON STATE CA ZJP 95215 <br />ACCOUNT ADDREss TO SEND FEES AND CHARGEE: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING] <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1, the undersigned Applicant, certify that 1 am the Owner, Operator, Authorizer) 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 ACCOUNTADDRESS 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 <br />Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, 1 hereby authorize the <br />release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br />HF.ALTHDEPARTNIENTas soon as it is available and at the same time it is provided to me or representative. <br />APPLICANT NAME (PLEASE PRINT) BRIAN MILLMAN 91 <br />TrrLE PROJECT GEOLOGIST TAzID# <br />FA 9:ASSIGNED <br />OWNER IO #:OI foAz�ar <br />ACCOUNT#: ^����� <br />I l <br />TO: <br />PR #: ACCOUNTING COMPLETED BY: , i /� <br />DATE: L2 -_D <br />9-3-2015 <br />Site Mitigation MFR 29- <br />