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SAN PQUIN COUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE 1 18 OCTOBER 2017 SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION; CNECRWOWNERMICORRENTLVONPREFinw EHD❑ <br /> PROPERTY PRITPAL F SINGH PHONE <br /> OWNERNAME PIRST M, I5T <br /> BUSINESS NAME SAVE ON GAS E#WLADOREBB <br /> OWNER HoMEADDRE58 420 WEST YOSEMITE AVENUE ATTENTION:ORCARE OF(OPTIONAL) <br /> Cm MANTECA STATE CA LP 95337 <br /> OWNER MAILINGADDRESB 420 WEST YOSEMITE AVENUE <br /> MAIuNDADDRESSC" MANTECA roNry� STATE CA LP 95337 <br /> C3 CORPORATION [I INDIVIDUAL E11 PARTNERSHIP ❑GOVERNMENTAGENCY ❑REBPONBNILE PARTY ❑OTNER <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD- ® RWQCB LEAD- ❑ DTSC LEAD ❑FED EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2954 <br /> 2950 2953 29601352613527 2965 <br /> FACILITY FILE:COMPLETE BUSINESS I SITEI PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No 191 <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES ® No ❑ <br /> BUBINEBBIFACILRYISTIEIPROJECTNANE SAVE ON GAS(FORMER RAINWATER CAR WASH) APN: 19-312-06 <br /> STIEADDRESSIPROJECTLDCATION 420 WEST YOSEMITE AVENUE BUBINE88PHONE <br /> Cm MANTECA STATE CA Zip 95337 <br /> BOARDOFSUPEwISOR DISTRICT LOCATION CODE KEY1 KE12 <br /> MAILING ADDRESS.IF DIFFERENT FROM FACIurYADDREe8 <br /> MAILING ADDRESS CRY STATE ZIP <br /> SIC CODE COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINEBSNAME ADVANCED GEOENVIRONMENTAL, INC ATTENTION:ORCAREOF(OPT L) <br /> MAILING ADDRESS 837 SHAW ROAD PWME (209)467-1006 <br /> Cm STOCKTON STATE CA ZIP 95215 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACIUTYIBUSINESS❑ THIRD PARTY BILLINGIN <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent, <br /> or Responsible Pany 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 ACCOUNTADDRESS for this site.I also certify that all information <br /> provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN <br /> JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned <br /> Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby authorize the <br /> release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representatlV <br /> APPLJCANT NAME(PLEASE PRINT) ERIN ROTTACKER SIGNATURE <br /> TITLE STAFF GEOLOGIST TMIDN <br /> FAN: WA-xin I,/J OWNERID N: 2L pT. AOOOUNT N: �(/, ASSIGNED TO: <br /> PRN: 2 2,3;23 ACCOUNTING COMPLETED BY; 7 DATE: / <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECKN RECVD BY DATE SERVICE REQUESTN INVOICEN <br /> Work Plan 2903 523 $456.00fS�C00143 Z,'1 <br /> 2904 523 $760.00 <br /> Site Mitigation MFR 29-XXX 8-1-2017 <br />