Laserfiche WebLink
DATE September 14, 2017 <br />SHADED AREAS FOR EHD USE <br />OWNER <br />CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD PARTY INFORMATION: FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE <br />PROPERTY <br />OWNER NAME <br />Raymond Farmer PHONE <br />FIRST MI LAST <br />BUSINESS NAME Ray Farmer Enterprises Inc. <br />E-MAIL ADDRESS <br />OWNER HOME ADDRESS ATTENTION: ORCARE OF (OPTIONAL) Linda Wilson <br />STATE <br />Cm <br />ZIP <br />OWNER MAILING ADDRESS 2606 Sheridan Wy. <br />STATE CAZIP <br />MAIUNG ADDRESS CITY Stockton <br />9 5 2 0 7 <br />CK CORPORATION INDIVIDUAL 0 PARTNERSHIP Li GOVERNMENT AGENCY Li RESPONSIBLE PARTY E OTHER <br />ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />EHD LOCAL VOLUNTARY <br />CLEANUP <br />2953 <br />III RWQCB LEAD- DTSC LEAD <br />2959 <br />El El El RWQCB LEAD- NI II FED EPA LEAD <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />2954 <br />ATTENTION: ORCARE OF (0P770NAL) J eanne Homsey BUSINESS NAME ATC Group Services LLC <br />PHONE 209-579-2221 MAILING ADDRESS 1117 Lone Palm Ave. Suite 201B <br />CITY Modesto STATE CA IP 95351 <br />SAN Jc UIN COUNTY ENVIRONMENTAL HEALTH r- PARTMENT <br />SITE MITIG,-‘rION MASTER FILE RECORD INFOt...ATION FORM <br />"MFR"- GREEN FORM <br />r/WILI I I 11-IL.. ‘..n.neir-i-s.. • s- ••••••••••.........• • ....• • •-• • ........-..- • .•.• ........... <br />IS PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? THIS A NEW YES D No 01 <br />Is THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES bli No 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME Toyota Town Inc. APN: 139-060-33 <br />SITE ADDRESS ! PROJECT LOCATION 610 N. Hunter St. <br />BUSINESS PHONE <br />CITY Stockton <br />STATE CA ZIP 95202 <br />BOARD OF SUPERVISOR DISTRICT 1 LOCATION CODE _ KErI Kea - <br />MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />SIC CODE COMMENT: <br />THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: OINNER0 FACILITY/BUSINESSO THIRD PARTY BILLING[] <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 AccouNrADDRESS 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 my representative. <br />APPLICANT NAME (PLEASE PRINT) si" „.....Te_avvvuLA SIGNATURE <br />TAX ID# TITLE — <br />FA #: .F-Aw..2 3 717 OWNER ID #0 1,000 223 3 I ACCOUNT #: Aka...1+13 2„s_ ASSIGNED TO: <br />PR #: -pleosz_tii,,3 ACCOUNTING COMPLETED BY: diz9 DATE: j <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REINES # INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 4 95-cr.) 0500 t..--y cl 11-1111 S F-00 .1 gOz--3 <br />Site Mitigation MFR 29- XXX 8-1-2017