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SAN J IUIN COUNTY ENVIRONMENTAL HEALTH ARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 11/11/2016 SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD LII <br />PROPERTY <br />OWNER NAME <br />Roger Hartley PHONE <br />8231400 FIRST MI LAST <br />BUSINESS NAME <br />Former Boulevard Automotive Service <br />E-MAIL ADDRESS <br />OWNER HOME ADDRESS <br />P.O Box 1962 , Manteca, CA, 95336 ATTENTION: ORCARE OF (OPTIONAL) <br />CITY -STATE tockton CA <br />ZIP <br />95215 <br />OWNER MAILING ADDRESS same as above <br />MAILING ADDRESS CITY STATE ZIP <br />0 CORPORATION <br /> 0 INDIVIDUAL El PARTNERSHIP <br /> El GOVERNMENT AGENCY 0 RESPONSIBLE PARTY <br /> <br />0 OTHER <br />ENVIRONMENTAL EHD LOCAL VOLUNTARY El RWQCB LEAD— RWQCB LEAD — <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />M 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 0 <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES w <br />No 12 <br />No 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME <br />Boulevard Automotive Service <br />APN: <br />128 080 30 <br />SITE ADDRESS / PROJECT LOCATION <br />2151 Country Club Boulevard <br />BUSINESS PHONE <br />209-823-1400 <br />CITY <br />Stockton <br />STATE <br />CA <br />ZIP <br />95204 <br />BOARD OF SUPERVISOR DISTRICT 1 LOCATION CODE KEY1 KEY2 <br />MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS <br />P.O Box 1692 <br />MAILING ADDRESS CITY Manteca STATE <br />CA <br />ZIP <br />95336 <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 Advanced GeoEnvironmental Inc. ATTENTION: OR CARE OF (OPTIONAL) <br />Daniel Villanueva <br />MAILING ADDRESS <br /> PHONE <br />837 Shaw Road <br />209-467-1006 <br />CITY Stockton STATE <br />CA <br />ZIP <br />95215 <br /> <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br /> <br />OWNER0 <br /> <br />FACILITY/BUSINESS0 <br /> <br />THIRD PARTY BILLINGE <br /> <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 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 m representative. <br />APPLICANT NAME (PLEASE PRINT) Daniel Villanueva SIGNATURE <br />TITLE <br />Senior Project Geologist <br />FA #: F A Ano2 3 23"=„3. <br />OWNER ID <br /># b 0002-2-2-.2-2-- <br />ACCOUNT tiAR4/.„1 ASSIGNED TO: <br />DATE: PR #: , <br />-t-R-05-4/s7(a <br />ACCOUNTING COMPLETED BY: <br />TAX ID # <br />9-3-2015 <br />Site Mitigation MFR 29-