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SAN JO` 'IN COUNTY ENVIRONMENTAL HEALTH ' -1ARTMENT 1RIM ED <br /> SITE MITIGP%i ION MASTER FILE RECORD INFORI CATION FORM <br /> "MFR"-GREEN FORM AUG 2 3 2017 <br /> DATE 2I j — SHADE0V)AR-1 PFRIMIfiFERVIeES <br /> &t$:1FWfffIAI9WSE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHE0KAF0MVER/8CVMWAFnVONF1LEw9rH EHD ❑ <br /> PROPERTY L n n e I B a l l e w PHONE <br /> OWNER NAME FIRST MI LAST (858) 775-8885 <br /> BUSINESS NAME Susman Family Trust su�smanttustees@gmail.com <br /> OWNER HOME ADDRESS 2004 Mesquite Court ATTENTION:ORCARE OF(OPTIONAL) <br /> Cm Carlsbad STATE CA zP 92009 <br /> OWNER MAILING ADDRESS Same as home address <br /> MAILING ADDRESS CITY STATE LP <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 ® NO ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ NO <br /> BUSINESSIFACILITYISITEIPROJECT NAME Payless Shoes Source APN' j(_'2—'S-6 _ <br /> SITE ADDRESS/PROJECT LOCATION 434 D r . Martin Luther King Blvd BUSINESS PHONE (510) 410-1009 <br /> CITY Stockton STATECALP 95206 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS <br /> MAILING ADDRESS CITY STATE LP <br /> SIC CODE COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ATTENTION:OR CARE OF(OPTIONAL) <br /> Oh-t-u/1' <br /> MAILING ADDRESS ,.l `j y�p� _ PHONE r f u) � i b - J 'l b <br /> CITY (J STATE `CA J zip{ q(4 66(OJ V <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I 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 ACCOUNTADORESS 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 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 ENVIRONMENTAL <br /> 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) N a�-1,.c,�,,,, I�l(illl�v(�j^„ SIGNATURE <br /> TmETAxID# <br /> �t��L S f <br /> FA#: � j I_^ OWNER ID#:c !�PL71/� 1VZZJ(.� ACCOUNT#: n n,,^ /.��-"� ASSIGNED TO: <br /> PR#. /) 1.7- ACCOUNTINGCOMPLETED BY: fj/ J CN per. DATE: / <br /> SR TYPE / PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan 2903 523 $456.00 <br /> 2904 523 $760.00 <br /> Site Mitigation MFR 29-XXX 8-1-2017 <br />