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STATE CA ZIP 95215 CITY STOCKTON <br />THIRD PARTY BILLINGEI ACCOUNT ADDRESS TO SEND FEES AND CHARGES: FACILITY/BUSINESS0 OWNER0 <br />ATTENTION: ORCARE OF (OPTIONAL) BUSINESS NAME ADVANCED GEOENVIRONMENTAL <br />MAILING ADDRESS 837 SHAW ROAD PHONE 209-467-1006 <br />SAN Jo' IN COUNTY ENVIRONMENTAL HEALTH 'PARTMENT <br />SITE MITIMPtION MASTER FILE RECORD INFOR...ATION FORM <br />"MFR"- GREEN FORM <br />DATE 26 January 2018 SHADED AREAS FOR END USE <br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION.' CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD <br />PROPERTY <br />OWNER NAME <br />Charles & Donna Skobrak Trust I PHONE <br />209-465-2667 FIRST MI LAST <br />BUSINESS NAME MILLER TRUST PROPERTY E-MAIL ADDRESS <br />OWNER HOME ADDRESS 9947 EAST HWY 26 ATTENTION: ORCARE OF (OPTIONAL) <br />CITY STOCKTON STATE CA ZIP 95215 <br />OWNER MAILING ADDRESS SAME AS HOME ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />0 CORPORATION <br /> El INDIVIDUAL <br /> El PARTNERSHIP <br /> 0 GOVERNMENT AGENCY El RESPONSIBLE PARTY <br /> CI OTHER <br />. ENVIRONMENTAL . EHD LOCAL VOLUNTARY CI RWQCB LEAD- . RWQCB LEAD- MI DTSC LEAD IIII FED EPA LEAD <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />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 <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES <br />1:1 No El <br />0 No 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME LARRY'S AUTO APN: 139-320-13 <br />SITE ADDRESS! PROJECT LOCATION 308 NORTH GRANT STREET BUSINESS PHONE 209-465-2667 <br />CITY STOCKTON, CA STATE ZIP 95219 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYI KEr2 <br />MAILING ADDRESS 3031 WEST MARCH LANE <br />MAILING ADDRESS CITY STOCKTON STATE ZIP 95215 <br />SIC CODE COMMENT: <br />THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />Bil l INC A NIn C/INADI I A Nii'lL" <br />Res <br />thi! <br />pro <br />JO' <br />Ow <br />reit <br />HE, <br />AP <br />""-^""LEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, or <br />that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with <br />e address identified above as the ACCOUNT ADDRESS for this site. I also certify that all information <br />ld correct; and that all regulated activities will be performed in accordance with all applicable SAN <br />S and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned <br />r Responsible Party for the project located above under facility/site address, I hereby authorize the <br />ts, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br />available and at the same time it is provided to me or my rep ntative. <br />rILLANUEVA SIGNATURE <br /> <br />TITLE SENIOR PROJECT GEOLOGIST <br /> <br />TAX ID # <br /> <br />FA #: .F.,„0,3,, OWNER ID #: 006042 151 2_ ACCOUNT #: A koo 4/.276 q ASSIGNED TO: <br /> <br />: riezts_..__ <br /> <br />PR # 7/d77; ACCOUNTING COMPLETED BY: DATE: <br />SR TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECVD BY DATE SERVICE REQUES • INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 t a- i 1 1 I- 1)C ' VZ S (Z-00:Y11 1 li <br />Site Mitigation MFR 29- XXX 8-1-2017