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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />RECEIVED <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM JUL 18 2017 <br />"MFR"- GREEN FORM <br />DATE 7/18/2017 ..vinvilmtN r • • RisE sHApowfwg„ r - <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD <br />PROPERTY <br />OWNER NAME <br />Sunday Borges PHONE 209-835-7896 <br />FIRST MI LAST <br />BUSINESS NAME Cu la Davanis Trust E-MAIL ADDRESS <br />sunnyk56@sbcglobal.net <br />OWNER HOME ADDRESS 1314 Walnut ATTENTION: ORCARE OF (ORT7ONAL) <br />Cm( Tracy SIAM CA ZIP 95376 <br />OWNER MAILING ADDRESS Same as above <br />MAIUNG ADDRESS CITY STATE ZIP <br />LX[ CORPORATION <br /> <br />0 INDIVIDUAL <br /> <br />0 PARTNERSHIP <br /> <br />GOVERNMENT AGENCY 0 RESPONSIBLE PARTY <br /> LI OTHER <br />Zi ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />ll EHD LOCAL VOLUNTARY M RWQCB LEAD- M RWQCB LEAD- <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />l. 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 21 No 0 <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES 0 No t <br />BUSINESS/FACIUTY/SITE/PROJECT NAME City Garage APN: 235-023-01 <br />SITE ADDRESS / PROJECT LOCATION 604 West 11th Street BUSINESS PHONE <br />CITY Tracy STATE CALP 95376 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br />MAIU NG 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 />BUSINESS NAME ATTENTION: C7RCARE OF (2enaV4L) Partner Engineering and Science <br />MAILING ADDRESS 2150 Torrance Blvd, Suite 200 PHONE 310-615-4500 <br />STATE Torrance CA ZIP 90501 <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br /> <br />OWNEREI <br /> <br />FACILITY/BUSINESS <br /> <br />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 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 JOAOUIN COUNTY <br />ENVIRONMENTAL HEALTII DEPARTMENT as soon as it is available and at the same time it is I cT ie. <br />k <br />APPLICANT NAME (PLEASE PRINT) Brett Bova SIGNATURE <br />TITLE <br /> Staff Scientist Tax ID* <br />FA*: pri_D 16-1 OWNER 10 #: OW po 42 2,. 4, 1 se AccouNTA4.01) 4,4 4 if ASSIGNED TO: <br />PR*: e40 5-i.i.0 1/1 ACCOUNTING COMPLETED BY: <br />bib <br />DATE: ....7/24 11 i <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$390.00 $650.00 ._Ci&4/41- 4-)..) 0 07 7 9-6• <br />9-3-2015Site Mitigation MFR 29- XXX 6-2-2017