SITE INFORMATION AND CORRESPONDENCE_FILE 2

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SAN J, JUIN COUNTY ENVIRONMENTAL HEALTH r�RTMENT DATE11 ASTER FILE RECORD INFORMATION "MFR" GREEN FORM 4/16/13 MSITE MITIGATION&LOP SHADED AREAS FOR EHD USE ONLY OWNER IDS CASE# UNIT IV OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION; CHECK IF OWNER tS CURRENTL Y ON FILE wim EHO PROPERTY OWNER NAME Margaret Marci 7( 0' 465-6015 FIRST MI LAST PHONE NUMBER BUSINESS NAME E-MAIL ADDRESS OWNER HOME ADDRESS 20 Mobile Lane Cm Crescent City STATE CA ZIP 95531 OWNER MAILING ADDRESS Same as above MAILING ADDRESS CITY STATE zip ❑CORPORATION t`_J&DIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION X ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP WATER QUALITY HW PIPELINE INVESTIGATION LOP FACILITY ID III INV# AccouNTID PR#/ROX A>sl16NEDEYM.oYEE I LEADAGENtw:EHI,RWQCI5_DTSC_I1PA_. FACILITY FILE.COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES r�t❑vy No fJ IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES {?f> No ❑ BUSINESS/FACILITY/SITE/PROJECT NAME Marci Property SITE ADDRESS/PROJECT LOCATION 2969 Loomis Road SUITE# BUSINESS PHONE CITY Stockton STATE CAZJP 95205 BOARD OF SUPERVWOR DISTRICT / LOCATION CODE KEY1 KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) MAILING ADDRESS CITY STATE zip 81C CODE APN# COMMENT: 1? "/fo- 2.'L( THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME ATTENTION:ORCARE OF (OPTIONAL) MAILING ADDRESS PHONE CITY STATE zip ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNERLfX FACILITY/BUSINESS❑ THIRD PARTY BILLING❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,Authorized Agen4 or Responsible Party and I acknowledge that all PERWT FEES, PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this project will be billed tome at the address identified above as the ACCOUNT 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 JOAQUIN COUNTY ORDINANCE CODES and/or STA.NDARDs and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operator,Authorized Agent,or Responsible Parry f 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 JOAQUIN Co IRON tEN L L H DEPARTMENT 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 TAX 10# APPROVED BY I DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE 817E MmGATtoN AMOUNT PAID DATE Of PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WQAK DEAN PE FEE:; -1,5-(4,