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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECE <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM DEC 06 2017 <br />DATE 11/28/17 S H A <br />i_.FOli Willa-1E0i S E <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER Is CURRENTLY ON FILE WITH EHD x <br />PROPERTY <br />OWNER NAME <br />San Joaquin County PHONE (209) 953-7046 FIRST MI LAST <br />BUSINESS NAME San Joaquin County Public Works/General Services Department E-MAIL ADDRESS <br />jhernandezzavala@sjgov.org <br />OWNER HOME ADDRESS 44 N. San Joaquin Street, Suite 590 ATTENTION: ORCARE OF (0P770AIAL) Joshua Hernandez Zavala <br />Ore Stockton STATE CA ZIP 95202 <br />OWNER MAILING ADDRESS 44 N. San Joaquin Street, Suite 590 <br />',AAIUN° ADDRESS Crry Stockton STATE CA ZIP 95202 <br />IV' <br />D CORPORATION <br /> 0 INDIVIDUAL <br /> 0 PARTNERSHIP <br /> NI GOVERNMENT AGENCY 0 RESPONSIBLE PARTY <br /> LI CrrHER <br />ENVIRONMENTAL D EHD LOCAL VOLUNTARY <br />CLEANUP <br />2953 <br />E RWQCB LEAD - <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />RWQCB LEAD — <br />ASSESSMENT <br />2950 <br />WATER Quart"( (WDR) <br />2965 <br />DTSC LEAD FED EPA LEAD <br />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 [I] No Eil <br />IS THIS AN EXISTING PROJECT LOCATION, BuT A NEW SCOPE OF WORK? YES E1 No 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME San Joaquin County Motor Pool APN: 155-18-002 <br />SITE ADDRESS! PROJECT LOCATION 1810 E. Hazelton Avenue BUSINESS PHONE <br />(209) 953-7046 <br />CITY Stockton STATE CA ZIP 95206 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KErl Kea <br />MAIUNG ADDRESS ,IF DIFFERENT FROM FACILITY ADDRESS 44 N. San Joaquin Street, Suite 590 <br />MAIUNG ADDRESS CITY Stockton STATE CA ZIP 95202 <br />SIC CODE COMMENT: <br />THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />[ BUSINESS NAME ATTENTION: ORCARE OF (OPTIONAL) <br />MAILING ADDRESS PHONE <br />CITY STATE ZIP <br />IACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNERd FACILITY/BUSINESSO THIRD PARTY BILLINGD <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 andJor 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 • rmation to SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is pro ded pi'e r y r presentative. <br />APPLICANT NAME (PLEASE PRINT) I) 1-"k iNs,1 <br /> <br />SIGNATURE <br /> <br />TITLE As5 tL T A t\i ‘CZECTO ('EN E (UL. SERV ICE6 <br /> <br />'WIWI _ 6co 053 I. <br /> <br />FA N: 4 00 44.9 <br />OWNER ID #: "d / f ,,,,,D.z.4 /0 I L. ACCOUNT #: Ai 3 zoc.4nfl i <br />( <br />ASSIGNED TO: <br />- <br />PRO: FRO ch/O 2516, ACCOUNTING COMPLETED BY: DATE: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK* RECVD BY DATE SERVICE REQUEST# J INVOICE# <br />2903 <br />2904 <br />523 <br />523 Work Plan )s-3 <br />$456.00 <br />$760.00 "t Lt..i7 1 L le- 01). 1 Y-tY -) <br />Site Mitigation MFR 29- XXX 8-1-2017