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SAN JIG AN COUNTY ENVIRONMENTAL HEALTH C RTMENT SITE MITIGATION MASTER FILE RECORD INFORMATION FORM "MFR"-GREEN FORM DATE 01/11/2017 1 SHADED AREAS FOR EHD USE OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNERS CURRENTL Y ON FILE WITH EHD PROPERTY PHONE OWNER NAME FIRST M1 Lasr (970)685-3300 BUSINESS NAME Crop Production Services E-MAILADDRESS Brian.Du an,ac sa u.com OWNER HOME ADDRESS ATTENTION:ORCARE OF(OPTIONAL) Brian Duggan CITY STATE zip i OWNER MAILING ADDRE58 3005 Rocky Mountain Avenue MAILING ADDRESS CITY Loveland STATE Co ZIP 80538 CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ® RWQCB LEAD— ❑ RWQCB LEAD— ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) El DTSC LEAD El FED EPA LEAD 2959 2954 2950 2953 2960/352613527 2965 FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ® No ❑ BUSINESS/FACIU Y/SrWPROJECT NAME Crop Production Serv,ces APN: 1 43-150-04 SITE ADDRESS/PROJECT LOCATION 1905 N.Broadway Avenue BUSINESS PHONE 209-547-2600 CITY Stockton STATE CA ZIP 95205 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS MAILING ADDRESS CITY STATE ZIP SIC CODE COMMENT: THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAMERubik ATTENTION:ORCARE OF (OPTIONAL.) Stephen Meninger MAILING ADDRESS 320 Fiint Street PHONE 775-6220857 CITY Reno STATE NV Zip 89501 ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLINGS BILLING AND COMPLIANCE ACK\O11 LEDGME\T: 1, the undersigned Applicant, certify that I am the Owner, Operator,Authorized Agent, or Responsible Party and I acknowledge that all PERMIT FEES, PEAALTfEs,ENFORCEAfE:vT CHARGES and/or Hot RLF CHARGES associated with this project will be billed to me at the address identified above as the ACCOL'NTADDRESS for this site. I also certify that all information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable S.» JOAQIIN COUNTY ORDINANCE CODES and/or STANDARDS and SKATE and/or FEDERAL Laws and REGULATION'S. As the undersigned Owner, Operator, Authorized Agent, or Responsible Part1 for the project located above under facility/site add�ss, I hereby authorize the release of any and all results, reports, and other environmental assessment information to SAN 0AQL-1 ' COUNTY ENVIRON\IE\Tal. HEALTH DEPARTIIE\-r as soon as it is available and at the same time it is provided to me or a entativ APPLICANT NAME(PLEASE PRINT) Stephen Mennger SIGNATURE TITLE Senior Geologist TAx ID A 2T / FAA: -,q ^ OWNER ID k:f,, v ) of CJ 73 ACCOUNT 0: /I3�� ASSIGNED TO: PR A; ACCOUNTING COMPLETED BY: / 1 f� UC.I DATE: 9-3-2015 Site Mitigation MFR 29-