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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE I 5/2 5/18 SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK if OWNER IS CURRENTLY ON FILE WM ENO LI <br />PROPERTY <br />OWNER NAME <br />Raymond Investments PHONE <br />(209) 466-4526 FIRST MI LAST <br />BUSINESS NAME Raymond Investments Corporation E-MAIL ADDRESS <br /> <br />OWNER HONE ADDRESS 817 S. Center Street ATTENTION OR CARE OF (OPOONAL) : <br />CITY Stockton STATE CA ziP 95206 <br />OWNER MAILING ADDRESS 817 S. Center Street <br />MAIUNG ADDRESS CITY Stockton STATE CA zip 95206 <br />17I CORPORATION <br /> CI INOWIDUAL <br /> <br />0 PARTNERSHIP 0 GOVERNMENT AGENCY 0 RESPONSIBLE PARTY <br /> <br />0 OTHER <br />El ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />D EHD LOCAL VOLUNTARY <br />CLEANUP <br />2953 <br />El RWQCB LEAe- <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />RWQCB LEAD - El DTSC LEAD <br />2959 <br />o FED EPA LEAD <br />2954 <br />WATER QUALITY (VVDR) <br />2966 <br />FACILITY FILE: COMPLETE BUSINESS! SITE/ PROJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? <br />YES D No 171 <br />YES 0 No 0 <br />BusiNEss/FActurriSITE/PROJECT NAME Former Helena Chemical Facility Af3N 16336017 <br />SITE ADDRESS /PROJECT LOCATION 2245 W. Charter Way BUSINESS PHONE <br />CITY Stockton STATE CA ZIP 95206 <br />BOARO OF SUPERVISOR Disirsicsj I LOCATION CODE 1 Fut I 11- Kea 1 <br />MAILLNG ADORESS, IF DIFFERENT FROM FACILITY ADDRESS 817 S. Center Street <br />MAILING ADDRESS CITY Stockton STATE CA ZIP 95206 <br />SIC CODE COAWENT: <br />REQUESTOR's INFORMATION: <br />BUSINESS NAME Condor Earth Technologies, Inc ATTENTION <br />PHONE (209) 234-0518 "L'AmR"s 188 Frank West Circle Suite 1 <br />CITY Stockton STATE CA zu2 95206 EMAiL pane@condorearth.corn <br />I ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNERE FACILITY/13USINESS0 REQUEsTOR0 <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I 11111 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 use at the address identified above as the ACCOUNT ADDRESS 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 COMM' ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS, As the <br />undersigned (Amer, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby <br />authorize the release of ally and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY <br />ENNTRONNIENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />APPLICANT NAME (PLEASE PRINT) f\-) 61, re. k SIGNATURE - <br />TITLE 19 A <br />TAx ID f <br /> <br />FA I: <br />rAWiS3 F1 <br />OWNER ID 1: I ACCOUNT a' J1 4- <br />-30,,1 otQa.)ail,,ji .,4oci-i <br />7 ASSIGNED TO: <br />PR 1: -ppo -i4.68r .2....7____ s ACCOUNTING COMPLETED BY: 0 DATE: 41.42/ 5- <br />SR TYPE PE SC FEE INFO AMT REMITTED CHEM RECVD BY DATE SERVICE REQUEST# INVOICEit <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />6456.00 <br />$760.00 <br />x , . <br />q' 1510 I 'CLI / 1''L.k40 ( I I) > V'010 19 1.(a5 <br />Site Mitigation MFR 2-26-2018