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RECEIVED SAN J UIN COUNTY ENVIRONMENTAL HEALTH I >RTMENT DATE MASTER FILE RECORD INFORMATION"MFR" MAY 2 ORS FORM 11 11 SITE MITIGATION &LOP SHADED AREAS FOR EHD USE ONLY OWNER ID/ CASE B ENVI ONMEIJ�L P RMI-/S OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION. CHECK IF OWNER IS CURRENTL YONF/LE WITH EHD El PROPERTY OWNER NAME Joe Doran ( 2091 367-1273 FIRST MI LAST PHONE NUMBER BUSINESS NAME N/A E-MAILADORESS OWNER HOME ADDRESS 2416 Vintage Oaks Court CITY Lodi STATE CA zip 95242 OWNER MAILING ADDRESS Same as above MAILING ADDRESS CITY STATE zip ❑CORPORATION ]�NNDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP FACILITY IDS I INVE I ACCOUNT ID I PR N RO t AaSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB_OTSC_EPA FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES EPC No ❑ IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ NO Ux BUSINESS/FACILITYISITE/PROJECTNAME Doran Property SITE ADDRESS I PROJECT LOCATION 2811 E. Fremont Street SUITE# BUSINESS PHONE CITY Stockton, STATE CAziv 95202 BOARD OF SIIPERVRIOR DISTRICT / LOCATION CODE 1 KEW KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:OR CARE OF(OPTIONAL) 2416 Vintage Oaks Court MAILING ADDRESS CITY Lodi CA STATE zip 95242 SIC CODE A3q , -089^�-t, :2t9rT'- THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME Fremont Gate, LLC ATTENTION:ORCARE OF (OPTIONAL) Wayne Henry MAILING ADDRESS PO Box 5221 Ph # is Wayne's Agent (Dale Deboer) PHONE 209-578-1122 CITY Modesto, STATE CA zip 95355 ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING(3x BILLING AVD COMPLIANCE ACKNOw LEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent,or Responsible Part)-and I acknowledge that all PERSHT FLLS, PEVALTIL.S,ErvFORCIi.VIE:yT CHARGES and/or 110t'RL 1CHARGES associated with this project will be billed tome at the address Identified above as the ACCO('.VT ADDRESS 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'JOAQL'IN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operator,Authorized Agent,or Responsible Parry for the project located above under facility/site address,1 hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQ1 IN Cot NTy Nv'IRONNI NT 1.HEALTH EPARTMENT aS soon as it is available and at the same time it is provided to me or my representative. APPLICANT NAME(PLEASE PRINT) Rayno 1 d Kab 1 anow SIGNATURE TITLE Authorized Agent TAxIDN 26-327 441 (Fremont Gate, LLC) APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE SITE MITIGATwJ/l AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPTS CHECK# RECEIVED BY WORK PLAN PE FEE:$