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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION MASTER FILE RECORD INFORMATION FORM IIMFR GREEN FORM DATE 10/27/2015 SHADED AREAS FOR EHD USE OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IFOKWERISCuRRENTr.romFiLEwrrm EHD El PROPERTY Swaran Chouhan PHONE OWNER NAME IRSr ST 209-467-0305 BUSiNEss NAME Super Centex' Mart E-MAIL ADDRESS OWNER HOME ADDRESS 1632 Paoloa Place ATTENTION:ORCAREOF(OPTIONAL) CITY zip Manteca CA 95337 OWNER MAILING ADDRESS 1632 Paoloa Place MAILING ADDRESS CITY Manteca CA 95337 ❑CORPORATION ❑INDNIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑'' RESPONSIBLE PARTY ❑OTHER ❑ ENVIRONMENTAL ❑ EMD LOCAL VOLUNTARY © RWQCB LEAo— ❑ RWQCB LEAD— ❑ DTSC LEAD ❑FED EPA LEAD ASSESSMENT CLEANUP CORRECTIVEACTiON WATER QUALITY(WDR) 2959 2954 2950 2953 296013526/3527 2965 FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No El IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES M No ❑ 13USINEss1FACILrrY1SrrFfPRa41cTNAME Super Center Mart APN: 147-343-22 SITE ADDRESS I PROJECT LOCATION 701 East Charter Wad/ BUSINESS PHONE 209-467-0305 CRY STATE zip Stockton CA 95206 BOOF SUPERVISOR DISTRICT LQCATION CODE KEY1 KEY2 ARD MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS MAILING ADDRESS CRY STATE LP SIC CODE —� COMMENT: THIRD PARTY BILLING INFO.'COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINEssNAME Advanced GeoErvironemental Inc ATTENnON:ORCAREOF OPTIONAL) Daniel Villanueva MAILINGADDRESS 837 Shaw Road PHONE 209-467-1006 CITY STATE LP Stockton CA 95215 AccoUNTADDRESS ToSEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING© BILLING AND COMPLIANCE ACI NOWLEDGINIENT: I, the undersigned Applicant,certify that I am the Owner, Operator,Authorized Agent, or Rasponsible Party and I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEAfENT CHARGES and/or HOURLY CHARGES associated 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 provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN JO.AQUIN COUNTY ORDINANCE CODES and/or 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 hereby authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQULN COUNTY ENVIRONMENTAL HEALTH DEPARTINIENTas soon as it is available and at the same time it is provided to me or r resent ive. Daniel Villanueva APPLICANT NAME(PLEASE PRINT) SIGNATURE TITLE Project Geologist TAx1D# FA 0. _n OWNER ID#: ^ ACCOUNT#: ` ASSIGNED TO: f �1,co�1 PR#: 1 ACCOUNTING COMPLETED BY: L.� DATE: 9-3-2015 V Site Mitigation MFR 29-