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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE 03/1$/2014 MASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> SITE MITIGATION& LOP <br /> SHADED AREAS FOR EHO USE ONLY OWNER 100 CASE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK/F OWNER is CURRENTLYOAF FILE wirH EHD <br /> PROPERTYOWNER Yash I Mata a (209)470-2330 <br /> FIF25T Mt LAST PHONE NUMBER <br /> BUSINESSNAME AUTO CENTER CIRCLE PROPERTY E-MAILADDRESS YOSH@MATAOA.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 /> i <br /> CORPORATION INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP—WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> FACILITY 10 9 INV# ACCOUNT ID PR#1 RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD C RWQCB_DTSC`EPA <br /> Jokpv y <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES Z NO <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES NO <br /> BUSINESB/FACILITYIStTE/PROJECT NAME AUTO CENTER CIRCLE PROPERTY <br /> SITE ADDRESS I PROJECT LOCATION 3261 AUTO CENTER CIRCLE SUITE# BUSINESS PHONE 209-470-2330 <br /> CITY STOCKTON, ZIP 95212 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE I KEY1 Kler2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OP77ONAL) <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE APN/lk(:> COMMENT: <br /> v-vU,,1_5 <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESSNAME ENVIROASSESS ATTENTION:ORCARE OF (OPTIOAWL) <br /> MAILING ADDRESS PO BOX 1154 PHONE 877-529-6838 <br /> CITY BONHER8FERRY STATE ID ZIP 83805 <br /> ACCOUNT ADDRESS TO SENO FEES AND CHARGES: OWNER❑ FACILfrY/BUSINESS THIRD PARTY BILLING® <br /> BU.LING AND COMPLIANCE ACKNOW LEIK:MENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,:tutlrorked Agent or Responsible Party and 1 acknowledge that all PEItmil <br /> PEmi-jmt ,E.vFoRcEAfFATCmAR(zE1;andlor Houm v 01AR(:EC associated with this project will be billed to me at the address identified above as the Ac'Louvj'ADnRns for this sits 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 applicable SAN JOAQUIN COUNTY ORDINANCE CODFS aDd/or STANDARDS <br /> and STATE and/or FEDERAL Laws and RFGLLATIONS. As the undersigned Owner,Operator,Authorized Agent,or Respowible Purr <br /> y for the project Nreakd above under facility/site address,I hereby <br /> authoria the release of any And all results,reports,and other environmental assessment information M SAN JOAQIIIN COUVTS•ENVIRONMENTAL IIF.ALTH L ENT as soon as is available and at the <br /> same tore it is provided to me or my representative <br /> APPLICANT NAME(PLEASE PRINT) Y08H MATAGA r <br /> SIGNATURE <br /> TITLE OWNER TAX ID# Q /1-7 /(� <br /> APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY U v DATE ( _f <br /> SITE MITIGATION AmoUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED By WORK PLAN PE <br /> FEE:� S J 7� �•�-I-1� 1�1 /U� C.0 kJ� 2 t Q,-� <br />