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SAN sJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE 103/1812014 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> /(\\ <br /> SITE MITIGATION & LOP <br /> SHADED AREAE FOREHD USEDNLY OWNER ID# DWbb' � CAS[#PJM/(;�/ L/ UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: l0 1 CHEcxiFOwNERIs CuRRENnyaiv FaewlrH EHD <br /> PROPERTY OWNER Yosh Mata a (209)470-2330 L-J <br /> FIRST MI LAST PHONE NUMBER <br /> BUSINESSNAME AUTO CENTER CIRCLE PROPERTY E-MAILAODRESS YOSH®MATAGA.COM <br /> OWNER HOME ADDRESS 3261 AUTO CENTER CIRCLE PROPERTY <br /> CITY STOCKTON STATE CA ZIP 96212 <br /> OWNER MAILING ADDRESS SAME <br /> MAILING ADDRESS CITY same STATE ZIP <br /> CORPORATION INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENTAGENCY RESPONSIBLE PARTY El OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP_ <br /> 90;','>24 <br /> ITY ID# INV# ACCOUNT ID PR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:BHD X RWQCB_DTSC—EPA <br /> oaf-o�lj P905 iqK -Imo►{N� 777��`� <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES NO <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES NO <br /> BUSINESS/FACILITY/SITEIPROJECT NAME AUTO CENTER CIRCLE PROPERTY <br /> SITE ADDRESS/PROJECT LOCATION 3261 AUTO CENTER CIRCLE SUITE# BUSINESS PHONE 209-470-2330 <br /> CITY STOCKTON, ZIP 95212 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEv2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE APN/11�oCOMMENT: <br /> u o1c>,►3 <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ENVIRO ASSESS ATTENTION:ORCARE OF(OPrmx) <br /> MAILING ADDRESS PO BOX 1154 PHONE 877-629-6838 <br /> CITY BONNERSFERRY STATE ID ZIP 83806 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER[:] FACILITY/BUSINESS11 THIRD PARTY BILLING® <br /> BILLING AND COMPLIANCE.ACKNONYLEDC:MENI': I,the undersigned Applicant,Certify that I am the(h4wer,Operalor,Aut/rorked Agent,or Responsible%urry and 1 acknowledge that a9 Plzlr.vn'HTE.S, <br /> Pv,w.ims,E.NF0RCt:61SAT Cim P,GE.S and/or NuuR1.Y CILIR(w s associated Nith this project will he billed to meat the address identified above as the Ac000NI"A01)Rf1;S for this,site. 1 also Certify that all <br /> Inlornranon provided on this application is true and Correct:and dal a)l reguhted nctivitics will be performed in acc'ordanc'e i%ith all applicable SAN JOAQUIN(AUNTY ORDINANCE C:ODFS and/or SfAND.ARUS <br /> and STATE and/or FEDERAL Laos and REGULATIONS. As the undersiimed 0I,7wr,Operator,Authorked Agent,or Resnvnvible Party for the project located above under Facility/site address,1 hereby <br /> authorize the release ofany and all results,reports,and other environmental as�cssnxat inforantion to S,4NJO%QUIN COUNTY ENN11RONTIENIAL IIEALIH I)I500i IFNTas soon as is available and at the <br /> same time it is provided M me or m)representative. <br /> YOSH MATAOA <br /> APPLICANT NAME(PLEASE PRltr'r) SIGNATURE <br /> TITLE OWNER TAX ID# <br /> APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYAMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK 11-AN PE <br /> FEE:�375 -S-75 L�_( I� l fk-"!K f� /07— �UMJ <br />