Laserfiche WebLink
SAN J*IN COUNTY ENVIRONMENTAL HEALTH *RTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> PATE 18 APRI L 2018 SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNERI RESPONSIBLE PARTY INFORMATION: ONECH/FOHWEnis0iAv urnroAFaEW?H EHD <br /> PROPERTY I PRITPAL I SINGH PHONE <br /> OWNER NAME IRST ST <br /> BUSINESSNAME SAVE ON GAS E-MAIL ADDRESS <br /> OWNER HOME AoDREas 420 WEST YOSEMITE AVENUE ATTENTION:MOARE OF(OPnONOL) <br /> Cm MANTECA srATE CA zip 95337 <br /> OWNER MAILING ADDRESS <br /> MAIUNGADDRESSCm STATE zip <br /> ❑CORPO nm ❑INDIVIDUAL IJ PAarNERSHIP ❑GOVERNMENTAOENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD- IN RWQCB LEAD- <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) ❑ DTSC LEAD FED EPA LEAD <br /> 2950 2953 29601352613527 2965 2959 2954 <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: ,,yy <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO In <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES In NO ❑ <br /> BUSINESSIFACILmISnEIPNOJECTRAME SAVE ON GAS(FORMER RAINWATER CAR WASH) APN 219-312-06 <br /> 8m ADDRESSIPRaECTLOCATION 420 WEST YOSEMITE AVENUE BUSINESSPHONE <br /> Cm MANTECA STATE CA zip 95337 <br /> BOAROOFSUPERVISORDISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILINGADDRESS,IFDIFFERENTFROMFAciL ADDRESS <br /> MAIUNGADDRESSCm STATE zip <br /> SICCODE COMMENT: <br /> REQUESTOR'S INFORMATION: <br /> BUSINEm NAME ADVANCED GEOENVIRONMENTAL INC ATTENTION <br /> MAILING ADDRESS 837 SHAW ROAD PHONE (209)467-1006 <br /> Cm STOCKTON STATE CA ZIP 95215 EMAIL <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ REQUESTOR® <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am 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 me 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 COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the <br /> undersigned Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby <br /> authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is proWled tome or y resentative. <br /> APPLICANTNAME(PLEASEPRINT) ERIN ROTTACKER SIGNATURE ` lA ^ ` ' A A <br /> TITLE STAFF GEOLOGIST TAxID# •�v <br /> FA#: M OWNER IO#: O ACCOUNT#: n ,l�/ ASSIGNEDTO: <br /> PR# gyp,S7 �2T ACCOUNTINOCOMPLETEDBY: IC TT DATE: S / <br /> SR TYPE r�EJ PPE S`C',J FEE INFO AMT REMITTED FCHECK# RECV'D BY DATE7 SERVICE REQUEST# INVOICE# <br /> Work Plan 2903 523 $456.00 <br /> 2904 623 $760.00 <br /> Site Mitigation MFR 2-26-2018 �O <br />