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RECEIVED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DtrARTMENT <br /> DATE 5_2 y_i 3 MASTER FILE RECORD INFORMATION "MFR" MAY 2 dF4W@ FORM <br /> /� �/f �{ SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER IDR r CASE#SR� " Z �+ ENVP 0 N�M/ry�L� <br /> 1h/ ` <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER/S CURRENTL Y ON FILE WITH EHD <br /> PROPERTY OWNER NAME Joe Doran 20)9 367-1273 <br /> FIRST Ml LAST PHONE NUMBER <br /> BUSINESS NAME N/A E-MAIL ADDRESS <br /> OWNER HOME ADDRESS <br /> 2416 Vintage Oaks Court <br /> CITY Lodi STATE CA zip 95242 <br /> OWNER MAILING ADDRESS Same as above <br /> MAILING ADDRESS CITY STATE zip <br /> ❑CORPORATION :@�NDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> fAcalTv 10# INV# ACCOUNT ID PR RO# AiSmw EMPLOYEE LEAD AaEICY:END RWCM DTSC_EPA <br /> �1 37LCE 053 <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BYTHE ENVIRONMENTAL HEALTH DEPARTMENT? YES &C NO ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ NO lox <br /> BUSINESS/FACILITY/SITEIPROJECTNAME Doran Property <br /> SITE ADDRESS/PROJECT LOCATION 2811 E. Fremont Street SUITE# BUSINESS PHONE <br /> CITY Stockton, STATE CAz'P 95202 <br /> BOARD OF SUPERVISOR DISTRICT / LOCATION CODE 1 KEYS KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:OR CARE OF(OPTIONAL) <br /> 2416 Vintage Oaks Court <br /> MAILING ADDRESS CITY Lodi CA STATE zip 95242 <br /> FSIC CODE = APN# COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESSNAME Fremont Gate, LLC ATTENTION:ORCARE OF(OPT/ONAL) Wayne Henry <br /> MAILING ADDRESS PO Box 5221 Ph # is Wayne'S Agent (Dale Deboer) PHONE 209-578-1122 <br /> CITY <br /> Modesto, STATE CA zip 95355 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER[—] FACILITY/BUSINESS❑ THIRD PARTY BILLINGI?JX <br /> BILLING AND COMPLIANCE.ACKNOWLEDGMENT: 1,the undersigned.Applicant,certify that 1 am the Owner,Operator,Authorized Agent,or Responsible Party and 1 acknowledge that all PER.WIT FEES, <br /> PENALT/ES,E:\'FORCEtrENT CHARGES and/or HOURLY CHARGES associated with this project Will be billed to me at the address identified above as the ACCOUNT ADDRESS for this site. I also certify that all <br /> informationprovided 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,1 <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY Nv'IRONM NT.AL HEALTH EPART\IENT 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) Rayno 1 d Kab 1 avow SIGNATURE 14 <br /> TITLE Authorized Agent TAx10# 26-327 441 (Fremont Gate, LLC) <br /> APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE 5-11-4-11 <br /> SITE MITIGATION AMOO`UNT PAID GATE OF PAYMENT PAYME/N,T TYPE RECEIPT/ CHQECK# RECEIVED BY WORK PLAN PE <br /> v ItArTi <br />