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SAN JO" UIN COUNTY ENVIRONMENTAL HEALTH ,-PARTMENT <br /> SITE MITI*ION MASTER FILE RECORD INFO&TION FORM <br /> "MFR"-GREEN FORM <br /> DATE 21 July 2017 SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECKTFONwrR1sCuRREHTLrONF1LERYR/EHD <br /> PROPERTY Jianping Wang PHONE <br /> OWNER NAME I rIRST ST (209)390-7218 <br /> BUSINESS NAME No Business name-Lawnmower Repair Yard-(Fernando's Place) E-MAILAODREeS NA <br /> OWNER HOME ADDRE88 1903 Ralph Avenue ATTENTION:ORCARE OF(OPROKAL) <br /> CITY Stockton STATE CA IJP 95206 <br /> OWNER MAILING ADDRESS Same as above <br /> MAILINGADDRESSCITY Stockton STATE CA LP 96206 <br /> ❑CORPOMT10N I@ INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARYL� RWQCB LEAD— [:1RWQCB LEAD— EJDTSC LEAD F-1FEDFED EPA <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2954 <br /> 2950 2953 1 29601352613527 2965 <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION N T PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No 9 <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ® No ❑ <br /> BUSINESS/FACILRY'S E/PROJEMNAME Fernando's Place APN' 147-160-03 <br /> SITE ADDRESS I PROJECT LOCATION 1201 South Center Street BUSINESS PHONE <br /> (209)467.1006 <br /> CITY Stockton STATE CA zip 95206 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILm ADDRESS <br /> MAILING ADDRESS CRY STATE ZIP <br /> SICCODE COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINE88 NAME Advanced GeoEnvironmental,Inc.(AGE) ATTENTNIN:ORCARE OF (OPnONALJ <br /> MAILINGADDRESS 837 Shaw Road PHONE <br /> Cm Stockton STATE CA ZIP 95215 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLINGIX <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that 1 am the Owner, 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 ACCOUNTADURESS 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 Parry 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 JOAQu.�N COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my repre tative. <br /> APPLICANT NAME(PLEASE PRINT) Brian Millman SIGNATURE <br /> TITLE Project Geologist TAXIOM <br /> FAM: 15 OWNER ID M: ACCOUNT#: ^ � ASSIGNED TO: <br /> PRM: P-?o91 ACCOUNTING COMP[LENTEDLB-YY: DATE: <br /> 9-3-2015 <br /> Site Mitigation MFR 29- <br />