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MAILING ADDRESS 1117 Lone Palm Ave., Ste. 201B PHONE 209-579-2221 <br />BUSINESS NAME ATC Group Services LLC ATTENTION <br />Jeanne Hornsey <br /> <br />CITY Modesto STATE CA ZIP 95351 <br />EmAlL jeanne.homsey@atcgs.com <br />SAN JOA .4 COUNTY ENVIRONMENTAL HEALTH C RTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE May 23, 2018 SHADED AREAS FOR EHD USE <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 />Raymond Farmer PHONE <br />FIRST A/11 LAST <br />BUSINESS NAME Ray Farmer Enterpri ses Inc. E-MAIL ADDRESS <br />OWNER HOME ADDRESS ATTENTION: ORCARE OF (0P770NAL) Linda Wilson <br />cn-y STATE ZIP <br />OWNER MAILING ADDRESS 2606 Sheridan Way <br />MAiuNG ADDRESs OTT Stockton STATE CA ZIP 95207 <br />DI CORPORATION <br /> E INDIVIDUAL <br /> LI PARTNERSHIP ID GOVERNMENT AGENCY <br /> 11] RESPONSIBLE PARTY <br /> E OTHER <br />I ENVIRONMENTAL M EHD LOCAL VOLUNTARY Zi RWQCB LEAD— IN RWQCB LEAD— <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />II 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 E No E <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES XI No El <br />BUSINESS/FACILITY/SITE/PROJECT NAME Toyota Town Inc. APN 139-060-33 <br />SITE ADDRESS! PROJECT LOCATION 610 N. Hunter St. BUSINESS PHONE <br />Or( Stockton STATE CA ZIP 95202 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br />MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />SIC CODE COMMENT: <br />REQUESTOR'S INFORMATION: <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: OVVNERD FACILITY/BUSINESSO REQUESTORN <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 and/or 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 information to SAN JOAQUIN COUNTY <br />ENVIRONMENTAL 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) v JçQIAA,SeS-r SIGNATURE <br />TITLE <br />FA #: F-AA:02_3a. 7 OWNER ID #: 0z/0,22453 ( ACCOUNT #: itRzo ‘1,132....s ASSIGNED TO: <br />PR #: .R. 0.5 e_ti 613 ACCOUNTING COMPLETED BY: DATE: 5730 8- <br />SR TYPE PE Sc FEE INFO AMT REMITTED CHECK# REM) BY DATE SERVICE REQUEST# INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 - -$n0 102.14t9 1.- )( I ) 1 ( S 1-z; -.)-1 ,"1 ?Al <br />1----)2 (-4y\A\ TAxID# <br />Site Mitigation MFR 2-26-2018