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San Toaquin County Environmental Health Department <br /> DATE 3-05-2015 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> /� <br /> SITE MITIGATION & LOP <br /> I <br /> SHADED AREAS FOR EHD USE ONLY OWNER ION 0 /Vin 767 CASE#5RW71// � UNIT IV <br /> OWNER FILE:COMPCErEPROPERTY OWNER/RESPONSIBLE PARTY INFORMAnolv., (CHEo,Ytr OWNER CuRREmTLroMcrcEwirH EHD <br /> PROPERTY OWNER NAME FAIRWAY ESTATES LLC ( 929 681-4393 <br /> Fast Ml Last PHONE NUMBER <br /> BUSINESS NAME EMAIL ADDRESS <br /> Fairway Estates <br /> Owner Home Address <br /> 2151 Salvio Street Suite 325 <br /> City STATE 7JP <br /> Concord CA 94520 <br /> Owner Melling Address <br /> Same as Above <br /> MailingAddressAddress City State 7JP <br /> CJ CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY l]RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION—ENVIRONMENTAL As SESSMENTX VOLUNTARY CLEANUP—WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> _ <br /> ".\ FACILITY ID# INV# AccoUNTID PR#/ILO# ASSIGNED EMPLOYEE LEAo AGENcr.EHD_RWQCB_DTSC_EPA <br /> 114"_�go8 4ALYA834 JP ffwuy <br /> FACILITYFILE: CommErEBUSINESS ISITE/PROJECT/NFoNMAnoN. yN- <br /> Is this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes L`J No ❑l <br /> IS this an ExISTING Project LOCATION but a NEW SCOPE OF WORK? Yes [3No M <br /> BUSINESSIFACILm/SRFJPRwECT NAME Fairway Estates <br /> SITE ADDRESS I PROJECT LOCATION SURE# BUSINESS PHONE <br /> 1155 West Center Street (925)681-4393 <br /> Cm STATE LP <br /> Manteca CA 95337 <br /> BOARD OF SUPERVISOR DISTRICT \T LOCATmm CODE KEY1 KEYL <br /> Meiling Address HOIFFERENThoIImJJ�FaJc///tyAddress Attention:or Care Of(optional) <br /> 2151 Salvio Street Mr. Scott Fujihara <br /> Meiling Address City STATE YIP <br /> Concord CA94520 <br /> SIC CODE APN# a.t / O.3O COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Responsible Party identfied above. <br /> BUSINESS NAME Advanced GeoEnvironmental, Inc. Attention:Groans Of (optional) <br /> Mailing Address PHONE <br /> 837 Shaw Road 800 511-9300 <br /> CITY Stockton CAA IJP <br /> 95215 <br /> AG nuNTAnaaAas for fees and charges OWNER FACIIJTY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,Certify that I am the Ovaer,QpOYaor,Authorized Agam,or Responsible Patty and I acknowledge that ail P£R err Fres, <br /> PENALTIES,ENFORCEMENTCHARGEsand/or HouaLYCHARGESassociated\rid/this project N'Rl be billed to meat the address identified above a4 d1e ACrzuSTADDNESs for this site I also certify thatall <br /> information provided on this applies ion is true and correct;and dmf all regulated activities Tvill be performed in accordance with all applicable SAN JOAQUIN COuNry Ordinance Codes and/or <br /> Standards rad STATE and/or FEDERAL Laws and Regulations. As the undersigned Owner,Operator,Authorized Agen,or Responsible Party for die pmject loafed above under facility/site address,I <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONNWM'AL HEALTH DEPARTMENT as soon as it <br /> is available and at the same time it is provided tome or my representative. <br /> APPLICANT NAME(PLEASE PRINT) Robert Marty SIGNATURE <br /> # J <br /> TITLE President-AGE TAX ID <br /> APpr.vetl By I oat. A000uldlne OMDe Prome.W O C-*-W By Date <br /> SITE MITIGATION <br /> 'PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIYED BY WORK PLAN PE <br /> FEES J 3 3 3 5-fS dhw(, I I I / 2(t ( eaPA rbQ zo <br />