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ASSIGNED TO: <br />DATE: <br />:5Aoo.2_42_3( - ACCOUNT #: <br />PR #: 2.,2_,5 ACCOUNTING COMPLETED BY: <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEREC <br />VD <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM Pik 21..;6 <br />ENvi E AREAS FOR END USE DATE <br /> May 16, 2018 <br />HE/AL OWNER FILE : COMPLETE PROPERTY OWNEFt/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER ,ama ,,,e3r,p7, AI <br />Psopurry <br />OWNER NAME <br />George Betker PHONE 209-848-3272 <br />FIRST MI LAST <br />BUSINESS NAME Geo Properties, Inc. E-MAIL ADDRESS <br />OWNER NOME ADDRESS 2306 Jackie Court ATTENTION: ORCARE OF (OPNONAL) George Betker <br />crrY Oakdale STATE CA ziP 95361 <br />OWNER MAILING ADDRESS Same as above <br />MAIUNG ADDRESS CITY STATE ZIP <br />Li CORPORATION <br /> 0 INDIVIDUAL <br /> 0 PARTNERSHIP 0 GOVERNMENT AGENCY AFtEspousisti PARTY <br /> <br />0 OTHER <br />II ENVIRONMENTAL EHD LOCAL VOLUNTARY N RWQCB LEAD— <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />RWQCB LEAD— <br />AsspssmENT <br />2950 <br />CLEANUP <br />2953 <br />WATER QUALITY (VVDR) <br />2965 <br />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 111 No <br />IS THIS AN DUSTING PROJECT LOCATION, BUT A NEW SCOPE OF WoRK? YES 0 NO N <br />BUSINESS/FACILITY/STTEIPROJECT NA1AE Former JM Equipment Company APN 163-230-080 & -340 <br />SITE ADDRESS /PROJECT LOCATION 1245 W. Charter Way BUSINESS PHONE <br />Cmi Stockton STATE CA Z1 95206 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE K 1 KEY2 <br />MATUNG ADDRESS, IF DIFFERENT FROM FACIUTY ADDRESS Same <br />MAILING ADDRESS CITY STATE ZiP <br />SIC CODE COMMENT: <br />REQUESTOR'S INFORMATION <br />BUSINESS NAME Ground Zero Analysis, Inc. ATTENTION Jenny Weese <br />MAIUNG ADDRESS 1172 Kansas Avenue PHONE 209-522-4119 <br />CrrY Modesto STATE CA ZIP 95351 EMAIL jweese@groundzeroanalysis_corn <br />I ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNERIA FAcTLITYIBUsINESSO REQUESTORD <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 represen <br />APPLICANT NAME (PLEASE PRINT) CQ ‘?„. \C„ SIGNATURE <br /> <br />TITLE <br /> v c <br />TAxID# <br />SR TYPE PE se FEE INFO AMT REMITTED CHECK# RECNTO BY DATE SERVICE REQUEST# INVOICE# <br />2903 523 $456.00 Work Plan 2904 523 $760.00 4 - 4. 1....,._.)( 2 1 il ii, iviriscEie-4411-vtiT <br />Site Mitigation MFR 2-26-2018