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BUSINESS NAME ATC Group Services LLC <br />MAILING ADDRESS 1117 Lone Palm Ave. <br />ATTENTION: ORCARE OF (OP T/ONAL) Jeanne Homsey <br />PHONE 209-579-2221 <br />CITY <br />Modesto <br /> STATE CA Zip 95351 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH bLPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE September 8, 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 />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) inda Wilson <br />crre STATE LP <br />OWNER MAILING ADDRESS 2606 Sheridan Wy <br />MAIUNG AD D R Ess CITY Stockton <br />STATE C A zIP 95207 <br />n CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 GOVERNMENT AGENCY RESPONSIBLE PARTY 0 OTHER <br />in RW B LEAD - . ENVIRONMENTAL 1. EHD LOCAL VOLUNTARY R3I RWQCB LEAD- III DISC LEAD In FED EPA LEAD <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER ALITY (VVDR) <br />2965 2959 2954 <br />OJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEAL EPARTMENT? YES 0 No El <br />Is THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES III No 0 <br />BUSINESS/FACILITY/BITE/PROJECT NAME Toyota Town Inc. APN: 139-060-33 <br />SITE ADDRESS / PROJECT LOCATION 610 N. Hunter St. BUSINESS PHONE <br />CrrY Stockton STATE CAZIP 95202 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br />MAILING ADDRESS, IF DIFFERENT FROM FACILITY ADDRESS <br />MAIUNG ADDRESS CRY 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: OWNERD FACILITY/BUSINESSO THIRD PARTY BILLINGN <br />or Responsible Party and I acknowledge th <br />BILLING AND COMPLIANCE ACICNOWLEDGM <br />all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated <br />T: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, <br />with this project will be billed to me at the ddress identified above as the ACCOUNTADDRESS for this site. I also certify that all information <br />provided on this application is true and rrect; and that all regulated activities will be performed in accordance with all applicable SAN <br />JOAQUIN COUNTY ORDINANCE CODES nd/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned <br />Owner, Operator, Authorized Agent, or esponsible Party for the project located above under facility/site address, I hereby authorize the <br />release of any and all results, repo s, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br />HEALTH DEPARTMENT as soon as• available and at the same time it is provided to me or my representa ive. <br />APPUCANT NAME (PLEASE PRINT) yu__ 14 0 at C <br /> <br />SIGNATUR <br /> <br />TimE <br />-BrAv\-ck Ac,y-r- I C-0 S traellirt <br /> <br />TAX ID # <br /> <br />FA #: OWNER ID #: ACCOUNT #: ASSIGNED TO: <br />PR #: ACCOUNTING COMPLETED BY: DATE: <br />9-3-2015 <br />Site Mitigation MFR 29-