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I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION. CHECK IF OWNERM CURRENrL Y ONFILE W/rH EHD E1 <br /> PROPERTY PHONE <br /> OWNER NAMEIRSTLAST (559)443-2700 <br /> BUSINESS NAME Zack & Sons Poultry, LLC E-MAIL ADDRESS <br /> y ry, marvinscheidt@zacky.com <br /> 'ft6 t-HeMCOnpp6gg,Ue ATTENTION:OR CARE OF(OPr/ONAL) <br /> Fcfflsno, CA 73721 STATE zip <br /> OWNER MAILING ADDRE882020 S. East Avenue <br /> MAILING ADDRESSCRY Fresno,CA 93721 STATE zip <br /> CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> ❑■ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD— ❑ RWQCB LEAD— ❑ DTSC LEAD ❑FED EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2954 <br /> 2950 2953 2960/3526/3527 2965 <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES I11 No ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No 9 <br /> BUSINESS/FACILITYISITE/PROJECTNAME Zacky Farms-Stockton APN 163-260-07 <br /> SITE ADDRESS I PRoJECT LOCATION 1111 Navy Drive BUSINESSPHONE 209-948-0129 <br /> CITYStockton STAT ECA z'P 95206 <br /> BOARD OF SUPERVISORDISTRICT LOCATION CODE KEY1 KEY2 <br /> i <br /> fMAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS <br /> MAILING ADDRESS CITY STATE zip <br /> f <br /> 1 <br /> SIC CODE COMMENT: <br /> REQUESTOR'S INFORMATION: <br /> I <br /> BUSINE88NAME Geographic Services Inc. ATTENTION Ruxandra Niculescu <br /> f <br /> MAILING ADDRESS PO Box 4517 PHONE 916-385-0202 <br /> i <br /> CITY Citrus Heights <br /> STATE CA ZIP 95611 MI"'RUXANDRAN@GSIENVIRONMENTAL COM <br /> ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESSIiii] REQUESTOR❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent, <br /> i 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 ACCOUNT AUDREss 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 <br /> applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the <br /> undersigned Owner, Operator,Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby <br /> authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT. f <br /> as soon as it is available and at the same time it is provided to me or m ,re,p(r0esentattiiv[e. <br /> APPLICANT NAME(PLEASE PRINT) / +DEARV-IN S 4� QT SIGNATURE �f� <br /> TITLE Director of Finance 1T-ID# 46-1989252 <br /> FAM OWNER ID N: M �S ACCOUNT#: iWI _ ASSIGNEOTO: <br /> III: 5�3 I/ ACCOUNTING COMPLETED BY: C•(J� DATE: <br /> SR TYPE I PE T SCI l FEE INFO AMT REMITTED CHECK# I RECVD BY DATE SERVICE REQUESTtt l u INVOICE# <br /> Work Plan 2903 523 $456.00 <br /> 2904 523 $760.00 <br /> Site Mitigation MFR 2-26-2018 <br /> I <br />