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SAN Jrv,,iUIN COUNTY ENVIRONMENTAL HEALTH L,.,ARTMENT <br /> DATE ��_ /` 2 MASTER FILE RECORD INFORMATION"MFR" SITE <br /> FORM <br /> l J SITE MITIGATION&LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID$ CASE$ SRO-1>6850q UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER ISCURRENTZYONRLE W/TH EH ❑ <br /> PROPERTY OWNER NAME Victor Hernandes ( ) <br /> FIRST MI LAST PHONE NUMBER <br /> BUSINESS NAME Former Arro#p's Smog Shop E-MAIL ADDRESS <br /> OWNER HOME ADDRESS 4302 Boulder Creek Circle <br /> env Stockton STATE CA ZIP 95219 <br /> OWNER MAWNG ADDRESS SAME <br /> MAILING ADDRESS CITY STATE LP <br /> ❑CORPORATION ®INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID$ INV# �pACC 1OUUNNT ID PR AR-0 N ASSIGNED EMPLOYEEEf� <br /> ENOY:EHD_RWQCB_DTSC_EPA_ <br /> o�'f U�g2, Jv HNw <br /> FACILITY FILE:COMPLETE BUSINESS ISITE/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 /> BUSINESS/FACIUTY/SITE/PROJECTNAME Former Arroyos Smog <br /> SITE ADDRESS I PROJECT LOCATION 3012 East Waterloo Road SUITE$ BUSINESS PHONE <br /> CITY Stockton / STATE Cep 95205 <br /> BOARD OF SUPERVISOR DISTRICT - / LOCATION CODE KEY1 KEY2 <br /> MAIuNGADDRESS,IFDIFFERENT FROM FACILTTYADDRESS 4302 Boulder Creek Circle ATTENTION:OR CARE OF(OPTIONALJ <br /> MAiumADoRESBCITY Stockton, �F BTATtA QIP 95205 <br /> slccooE APN$ 143-130-24 COMMENT` <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME Vincent Hernandez ATTENTION:ORCARE OF(OPnOIWL) <br /> MAIuNGADDRESS 4302 Boulder Creek Circle PHONE 477-4362 <br /> CITY Stockton STATE ca zip 95219 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTYBILLINGLq <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the(honer,Operator,Authorized Agent'or Responsible Party and I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this project will be billed tome at the address identified above as the ACCOUNTADDRESS 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 applicable SAN JO UIN COUNTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operator,Authorized Agent,or Responsib5E � <br /> roje t located above under facility/site address,I <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY L H ALTH DEPARTMENT as soon as itis veil ble <br /> and at the same time it is provided to me or my representative. ��� <br /> APPLICANT NAME(PLEASE PRINT) Vincent Hernandez SIGNATURE <br /> TrrLE Owner TAX ID$ <br /> APPROVED BY DATE ACCWNTING OFFm PROCEsw4G COMPLETED BY DATE <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT I PAYMENT TYPE RECEIPT$ CHECK$ RECEIVED BY WORK PLAN PE <br /> FEE:$ 3 <br /> 6-2,G <br /> 7 <br />