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RECElvED <br /> SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORIJNv/oAR 0 4 Z019 <br /> "MFR"-GREEN FORM ONt(ENTDEPAL H`' T}� <br /> DATE —I'L i I I SHADEDARMA`61ic�cirfDLUSE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK/FOWNER/s CURRENTLYONFILEwtrH EHD <br /> PROPERTY PHONE <br /> OWNERNAME IRST MI ST G J3 <br /> 2..0 1 . 9 7. a 5 �} <br /> BUSINESS NAME �I t �;,�/I i)-; 3��✓I -�-� avv�E-MI(A V IRSS(A IVi0 VVA S r�` CSI001-f ov l r I O l/ <br /> OWNER HOME ADDRESS V 1 t- ATTENTION:ORCARE OF(OPT70NAL,) /VI lJ <br /> CITY STATE ZIP <br /> OWNER MAILING ADDRESS 4 CD ` ctc�,� 11,1/, I V' (�I�/p li-� .+.�1 I� I Q Q�.. <br /> MAILING ADDRESS CITY u-I C,CK''C/VI lVl Lim 4 STATE CA <br /> 21P w /.� / <br /> ❑CORPORATION l ❑INDIVIDUAL ❑PARTNERSHIP M GOVERNMENT AGENCY ❑RESPONSIBLE PARTY L❑-OTHER <br /> ® ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD— ❑ RWQCB LEAD— <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) El DTSC LEAD El FED EPA LEAD <br /> 2950 2953 29601352613527 2965 2959 2954 <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/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 ANEW SCOPE OF WORK? YES ❑ No ❑ <br /> BUSINEssrFACILmISITEmaOJECTNAME Stockton-S.Airport Way-Phase 1/111 argeted Brownfields Assessment APN 169-077-030-000 <br /> SITE ADDRESS I PROJECT LOCATION 2135 S. Airport Way BUSINESS PHONE <br /> CITY Stockton STATECAZIP 95206 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE COMMENT: <br /> REQUESTOR'S INFORMATION: <br /> BUSINESS NAME ATTENTION <br /> MAILING ADDRESS PHONE <br /> CITY STATE ZIP EMAIL <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER FACILITY/BUSINESS❑ REQUESTOR❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that 1 am the Owner,Operator,Authorized Agent, <br /> or Responsible Party and 1 acknowledge that all PER;111T FEES,PENALTIES,EA'F"0RCEA1EjVT 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 Responsihle Partly for the project located above under facility/site address, 1 hereby <br /> authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQt1IN COAST) <br /> ENVIRONIIIE\TAI,HEAI,TII DF,1-PARTNIENTy1a-}s'soon as it is/a'vVaila/bI le/aIn/dt at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) V� O� ," G l V�U�IU L/I 1✓ IOlY�<SIGNATURE r�����n�) L4 1 / Y� �,J�/�`'_/ /1 <br /> TITLE .n!I.I �to�r f-( <br /> I-�1 l r �� _, TAx ID# <br /> t, lit � C <br /> FAN: r na2l 1:L �.. OWNER ID#: 1/ ACCOUNT#: D)�J'�(.I_��L{_� A991GNED TO: <br /> PRN: n�-(J �' j ACCOUNTING COMPLETED BY: ( l '\Lel T ( � DATE: , <br /> SR TYPE /[ PE SC FEE INFO AMT REMITTED CHECK# I RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan <br /> 2903 523 $456.00 <br /> 2904 523 $760.00nil <br /> Site Mitigation MFR 2-26-2018 <br />