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"RIEDDDD SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION MASTER FILE RECORD INFORMATION FORM DEC 18 1017 "MFR"- GREEN FORM DATE December 14, 2017 ENVIRONMENT HEALTHSHADED AREAS FOR EHD USE OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS 04IRRENTLYON FILE W/rH EHD PROPERTY Lincoln Properties Ltd. PHONE (209)478 9200 OWNER NAME I F71-qsT I LAST BUSINE88NAME Sims-Grupe Management Corporation, Inc, E-MAIL ADDRESS OWNER HOMEADDRES8 374 Lincoln Center ATTENTION:ORCARE OF(OPT/ONAL) CITY Stockton STATE CA zip 95207 OWNER MAILING ADDRESS 374 Lincoln Center MAILING ADDRE88 CITY Stockton STATE CA Zip 95207 ®CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER ❑ ENVIRONMENTAL ❑ EHDLOCALVOLUNTARY ® RWQCBLEAD- ❑ RWQCBLEAD- ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) ❑ DTSC LEAD ❑FED EPA LEAD 2950 2953 2960/3526/3527 2965 2959 2954 FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES No ❑ IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No M BUSINESB/FACILRYISITeIPROJECT NAME Parkwoods Cleaners APN:077-280-32 SITE ADDRESS I PROJECT LOCATION 1744 West Hamner Lane BUSINESS PHONE CITY Stockton STATE CAz1P 9.5209 BOARD OF SUPERVISOR DISTRICT 2 LOOAnON CODE KEY-) KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS 374 Lincoln Center MAILING ADDRESS CITY Stockton STATE CA zip 95207 SIC CODE COMMENT: THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME ATTENTION:ORCARE OF(OP77ONAL) MAILING ADDRESS PHONE Cm STATE zip ACCOUNT ADDRE88 TO SEND FEES AND CHARGES: OWNER® FACILITY/BUSINESS❑ THIRD PARTY BILLING❑ BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner,Operator,Authorized Agent, or Responsible Party and I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGEs and/or HOURLY CHARGES associated with this project will be billed to me at the address identified above as the ACCOUNTADDREss for this site.I also certify that all information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUN STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner, Operator,Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN Cj:�IENTALHEALTH DEPARTMENT as so a tisayailawand at the same time it is provided to me or myrepvAPPLICANT NAME(PLEASE PRISIGNATURE TITLE 1 1� TAxIDS qiq FA#: OWNER ID S: AOOOUNT/: �--- ASSIGNED TO: PR 0' r �� ACCOUNTING COMPLETED BY: � DATE: SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST#-E INVOICE# Work Plan ]2904 903 523 $456.00 12 m 523 $760.00 6 ��! aLl"� lg`� C� Site Mitigation MFR 29-XXX 8-1-2017