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SAN*UIN COUNTY ENVIRONMENTAL HEALTHOARTMENT <br /> DATE05/13/2014 MASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IFO*WER/SCURRENTLYONFILE WITH E H D <br /> PROPERTY OWNER NAME Donald Rogers 20) 464-5780 <br /> FIRST MI LAST PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> N/A N/A <br /> OWNER HOME ADDRESS <br /> 11900 South Union Road <br /> CRY STATE LP <br /> Manteca CA 95336 <br /> OWNER MAILING ADDRESS 11900 South Union Road <br /> MAILING ADDRESS Cm STATE LP <br /> Manteca CA 95336 <br /> ❑CORPORATION/ ❑INDm=AL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ®RESPoNs18LE PARTY ❑OTHER <br /> SITE MITIGATION Q ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP—WATER QUALITY HW PIPELINE INVESTIGATION LOP_ _ <br /> FACILITY ID# INV# ACCOUNT 10 1 PR N400 I ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB X DTSC_EPA <br /> oomgy I Rcx')33 3 SatM'l <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 /> BUSINESSIFACILRY/SRE/PROJECT NAME <br /> The Transmission Store <br /> SITE ADDRESS I PROJECT LOCATION SURE# BUSINESS PHONE <br /> 515 West Charter Way <br /> Cm STATE LP9 5 2 0 6 <br /> Stockton CA <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> 11900 South Union Road Donald Rodgers <br /> MAIuNGADDRESS CITY STATE ZIP <br /> Manteca CA 95336 <br /> SIC CODE APN 91,f-r-O q Lf_Os, COMMENT: <br /> 1 ��l <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINEssNAME Advanced GeoEnvironmental, Inc. ATTENTIOWORCAREOF(aFrMNAL) William Little <br /> MAILING ADDREss 837 Shaw Road PHONE 800 511 9300 <br /> Cm Stockton STATE CA ZIP 95215 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER® FACILITY/BUSINESS❑ THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent,or Responsible Party and I acknowledge that all PERMITFEEs, <br /> PENALTrEs,ENFoacEmrENTCHARGES and/or HOUPLY CHARGES associated with this project will be billed to me at the address identified above as the ACCOUYTADDRESS for this site. 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 CODES and/or <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operator,Authorized Agent,or Responsible Party for the project located 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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available <br /> and at the same time it is provided to me or my representative. – <br /> APPLICANT NAME(PLEASE PRINT) William Little SIGNATURE ix�'� <br /> TITLE Geologist - Agent of Owner TAX ID# <br /> APPROVED BY DATE ACCOUNTING OFFK:E PROCESSING COMPLETED BY DATE <br /> SITE MITIGATIONDATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE: itt <br /> �9 o O <br />