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PH°NE 209-579-2221 MAILING ADDRESS 1117 Lone Palm Ave. <br />BUSINESS NAME ATC Group Services LLC ATTENTION: ORCARE OF (OPTIONAL) Jeanne Homsey <br />CITY Modesto STATE CA ZIP 95351 <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: <br /> <br />OWNERO <br /> <br />FACILITY/BUSINESSO <br /> <br />THIRD PARTY BILLING[ <br />TAX ID # <br />— <br />SIGNATURE <br />SAN Jc "YIN COUNTY ENVIRONMENTAL HEALTH 3ARTMENT <br />SITE MITI-L...10N MASTER FILE RECORD INFO", TION FORM <br />"MFR"- GREEN FORM <br />DATE March 7, 2017 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 />Raymond Farmer PHONE <br />FIRST MI LAST <br />BUSINESS NAME Ray Farmer Enterprises Inc. E-MAIL ADDRESS <br />OWNER HOME ADDRESS ATTENTION: ORCARE OF (OPTIONAL) Linda Wilson <br />crry STATE ZIP <br />OWNER MAILING ADDRESS 2606 Sheridan Wy <br />MAILING ADDRESS CITY Stockton STATE CA z'P 95207 <br />CORPORATION <br /> <br />INDIVIDUAL <br /> D PARTNERSHIP <br /> <br />GOVERNMENT AGENCY E RESPONSIBLE PARTY <br /> D 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 No M <br />YES Ea No E IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? <br />BusINEss/FAciuTy/SrTE/PRoJEcT NAME Toyota Town Inc. APN: 139-060-33 <br />SITE ADDRESS / PROJECT LOCATION 610 N. Hunter St. BUSINESS PHONE <br />CITY Stockton STATE CAD. 95202 <br />BOARD OF SUPERVISOR DISTRICT I LOCATION CODE I I Keil 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 />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 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 ENVIRONMENT AL <br />HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />vv.s.c..,./ <br />FA #: <br />64002 381. 7 <br />PR #: <br />OWNER ID #:006022_33 i ACCOUNT/0: Aeix,,i_i_132,c- ASSIGNED TO: <br />leo 3 ACCOUNTING COMPLETED BY: DATE: , .. / 1 q4/7 <br />TITLE <br />3(7117 <br />APPLICANT NAME (PLEASE PRINT) <br />9-3-2015 <br />Site Mitigation MFR 29-