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STATE CA ZIP 95215 CITY STOCKTON <br />THIRD PARTY BILLINGEI ACCOUNT ADDRESS To SEND FEES AND CHARGES: FACILITY/BUSINESS': OWNER': <br />ATTENTION: ORCARE OF (OPTIONAL) BUSINESS NAME ADVANCED GEOENVIRONMENTAL <br />MAILING ADDRESS ADVANCED GEOENVIRONMENTAL PHONE 209-467-1006 <br />SAN JC UIN COUNTY ENVIRONMENTAL HEALTH rs—PARTMENT <br />SITE MITk.. _NON MASTER FILE RECORD INFOR...ATION FORM <br />±MFR5- GREEN FORM <br />DATE 08 November 2017 SHADED AREAS FOR EHD 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 />Rodaet Hartley PHONE <br />209-823-1400 FIRST MI LAST <br />BUSINESS NAME FORMER BOULEVARD AUTOMOTIVE SERVICE E-MAIL ADDRESS <br />OWNER HOME ADDRESS P.O. Box 1692 ATTENT ON: OR CARE OF (OPTIONAL) <br />CITY MANTECA STATE CA ZIP 95336 <br />OWNER MAILING ADDRESS SAME AS HOME ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />1E1 CORPORATION <br /> <br />I: INDIVIDUAL <br /> <br />El PARTNERSHIP <br /> <br />1: GOVERNMENT AGENCY El RESPONSIBLE PARTY <br /> 11 OTHER <br />I ENVIRONMENTAL MI EHD LOCAL VOLUNTARY I 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 />I DTSC LEAD IN 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 IZ <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES Ei No I: <br />BUSINESS/FACILITY/SITE/PROJECT NAME BOULEVARD AUTOMOTIVE SERVICE APN: 123-080-30 <br />SITE ADDRESS! PROJECT LOCATION 2151 COUNTRY CLUB BOULEVARD BUSINESS PHONE 209-823-1400 <br />CITY STOCKTON, CA STATE ZIP 95204 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br />MAILING ADDRESS ,IF DIFFERENT FROM FACILITY ADDRESS P.O. Box 1692 <br />MAILING ADDRESS CITY MANTECA CA STATE ZIP 95366 <br />SIC CODE COMMENT: <br />THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, or <br />Responsible Party and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with <br />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 Parry 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 my representative. <br />APPLICANT NAME (PLEASE PRINT) DANIEL VILLANUEVA <br /> <br />SIGNATURE <br />TITLE SENIOR PROJECT GEOLOGIST <br /> <br />TAX <br />ID # <br /> <br />i 6 <br />OWNER ID #: 0 w 002.22:2_ f ACCOUNT #711 /, AS TO: 1163 <br />ACCOUNTING COMPLETED BY: 7,,, DATE: <br />alr — <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# REMIT BY PATE j SERVICE REQUEST!!i INVOICE!! <br />Work Plan 2903 <br />2904 <br />523 <br />523 $760.00 <br />$456.00 70 v•-• <br />f 134 '7 S1-00 7447 <br />Site Mitigation MFR 29- XXX 8-1-2017