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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE SHADED AREAS FOR END USE <br /> OWNER FILE:COMPLETE PROPERTY OWNERI RESPONSIBLE PARTY INFORMATION: CHECNlFOWNE7V is avRREmnyoNFiLE wrH END E <br /> PROPERTY Weldon Church - <br /> TRsr r D (510)524-0297 <br /> OWNER NAME <br /> BUSINESS NAME E-LWL ADDRESS <br /> OWNER HOME ADDRESS 3400 Wagner Heights Road ATTENTION.CIRCARE OF(OPY70MU) <br /> CrrY Stockton STATE CA zip 95209 <br /> OWNER MAILING ADDRESS 3400 Wagner Heights Road <br /> MAIUNGADDRESS CITY Stockton STATE CA AP 95209 <br /> [I9 <br /> CMPOR4TION 1 INDIVIDUAL ❑PARTNERSHIP ©0OVERNMENTAGENGY ®RESPDNSIBLB PARTY ❑OrHER <br /> ❑ ENVIRONMENTAL E] EHD LOCAL VOLUNTARY ] RWQCB LEAS— ElRWOOB�O'- E] OTSC LEAD [-]Fm <br /> n EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY MDR) 2959 2954 <br /> 2950 2953 29601352613527 2965 <br /> FACILITY FILF-,COMPLETE BUSINESS I SITEI PROJECT INFORMATION: <br /> Is THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES Q No KI <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES IJ No ❑ <br /> BUSINEs9IFAOILITYISITEMROJECT NAME Weldon Church Property APN: 233-153-13 <br /> SrrEADOREss1PRa1ECTLOCATIOH 104 West Beverly Place BUSINESSPHONE (800)511-9300 <br /> CITY Tracy STATE CA IJP 95376 <br /> BOAROOFSUAERVII Dl9TRIC7 L=ATION CODE LKEY11 KET2 <br /> MAILImo ADDRESS,IF DIFFERENT FROM FACILITY ADOREea 3400 Wagner Heights Road <br /> MAIUNoADDRessOrY Stockton CA STATE zip 95209 <br /> StO CODE COMMENT: <br /> THI Rn PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ADVANCED GEO ENVI RON MENIAL,INC. ATTENTION:ORCARE OF(OPnOMAL) <br /> MAIUNaADDREeS 837 SHAW ROAD PHONE (800)511-9300 <br /> Crry STOCKTON STATE CA IJP 95215 <br /> ACCOUNT ADDRESS TOSENOFEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRoPARTY BILLINGN <br /> BILLING AND COMPLIANCE ACIcgOWLEDGMEATi': I,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent, <br /> or Responsible Party and I acknowledge that all PERMIT FEES,PF.NALTfEs,ENFORCEMENT C11ARGE•S 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 /> Avner, Operator,Authorizer)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 ENVIRONNIENFAL <br /> HEALTH DEPARTMENTas soon as it is available and at the same time it is provided to me or my resentative. <br /> APPLICANT NAKE(PLEA,,PRINTI BRIAN MILLMAN SIGNATURE <br /> TITLE PROJECT GEOLOGIST TAxIDR <br /> FA X. OWNER IO ACCOUNT#: ASSIGNED TO: <br /> r4 66z3 2 S-Z D t/oozl`f 3 a2cj'�77.5~ <br /> PR#: ACC4UNTINO COMPLETED 8Y: <br /> DATE: l� <br /> 9-3.2015 <br /> Site Mitigation MFR 29- <br />