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SAN JG—, UIN COUNTY ENVIRONMENTAL HEALTH D,rARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> 11MFR11-GREEN FORM <br /> DATE 28 MARCH 2018 SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OwmER Is CaRREAm YON FILE wITH EHD <br /> PROPERTY Nancy Sanguinetti PHONE (559) 709-0942 <br /> OWNER NAME FIRST MI LAST <br /> BUSINESS NAME Sanguinetti Trust Property E-MAILADDRESS <br /> OWNER HOME ADDRESS 2928 Dwight Way ATTENTION:ORCARE OF(OP7IONAL) <br /> CITY Stockton STATE CA zip 95204 <br /> OWNER MAILING ADDRESS 2928 Dwight Way <br /> MAILING ADDRESS CITY Stockton STATE LP <br /> ❑CORPORATION ❑INDIVIDUAL PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> ® ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD- ❑ RWQCB LEAD- <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) ❑ DTSC LEAD [:1 FED EPA LEAD <br /> 2959 2954 <br /> 2950 2953 296013526/3527 2965 <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES IN No ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No IN <br /> BUSINESS/FACILRYISITdPROJECTNAME Sanguinetti Trust Property APN: 171-290-040 <br /> SITE ADDRESS/PROJECT LOCATION 2085 E. Mariposa Road BUSINESS PHONE <br /> CITY STOCKTON STATECA ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS <br /> MAILING ADDRESS CITY 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 /> BUSINESSNAME ADVANCED GEOENVIRONMENTAL, INC ATTENTION:ORCARE OF(OPTIONAL) <br /> MAILINGADDRESS 837 SHAW ROAD PHONE (209)467-1006 <br /> CITY STOCKTON STATE CA zip 95215 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLINGff <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant, certify that I am the Olvner,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 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, I hereby authorize the <br /> release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> 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) TIMOTHY J CUELLAR SIGNATURE ' <br /> TITLE PROJECT MANAGER TAXIDq <br /> FAM EA OWNER ID#: ;, )/\;� �" ACCOUNT#: S 7 <br /> ASSIGNED TO: <br /> PR#: �n,� ACCOUNTING COMPLETED BY: DATE: <br /> FSRE/((} PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> an 2903 523 $456.00 L x <br /> 2904 523 $760.00 +� I 7 UI � �O Z <br /> Site Mitigation MFR 29-XXX 8-1-2017 <br />