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MAILING ADDRESS 837 SHAW ROAD PHONE (209)467-1006 <br />BUSINESS NAME ADVANCED GEOENVIRONMENTAL, INC. ATTENTION: ORCARE OF (0P770NAL) <br />c" STOCKTON STATE CA ZIP 95215 <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: <br /> <br />OWNERD <br /> <br />FACILITY/BUSINESSO <br /> <br />THIRD PARTY BILLINGE] <br />SAN QUIN COUNTY ENVIRONMENTAL HEALTH 'ARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE /e2-M//1 SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EH!) <br />PROPERTY <br />OWNER NAME <br />Brooks Stratmore PHONE <br />FIRST MI LAST <br />BUSINESS NAME Elwood Investments, Inc. E-MAIL ADDRESS brooks@elwoodmvestments corn <br />OWNER HOME ADDRESS 34 Alamo Square, Suite 200 ATTENTION: ORCARE OF (OPTIONAL) <br />cny Alamo STATE CA ZIP 94507 <br />OWNER MAILING ADDRESS 34 Alamo Square, Suite 200 <br />MAILING ADDRESS CITY 34 Alamo Square, Suite 200 STATE CA ZIP 94507 <br />CI CORPORATION <br /> El INDIVIDUAL <br /> CI PARTNERSHIP <br /> LII GOVERNMENT AGENCY CI RESPONSIBLE PARTY <br /> 0 OTHER <br />IN ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />MI EHD LOCAL VOLUNTARY III RWQCB LEAD - IN RWQCB LEAD - <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />. DTSC LEAD III 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 IX No 0 <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES III No LX <br />BUSINESSIFACILITY/SITE/PROJECT NAME j WR - Elwood Equity Property "N: 167-070-30 <br />SITE ADDRESS (PROJECT LOCATION 2422 South California Street BUSINESS PHONE <br />CITY STOCKTON STATE CAZIP 95202 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <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: E 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 REGITLATiONs. As the undersigned <br />Owner, Operator, Authorized Agent, or Responsible Party 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 ENVIRONMENTAL <br />HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my sentive. <br />APPLICANT NAME (PLEASE PRINT) RENE TOTH <br />TITLE STAFF GEOLOGIST <br />SIGNATURE <br />TAX ID # <br />FA #: <br />161024A-1 / ( <br />OWNER ID #: <br />/Q n 1,00D-2 2 qg-( <br />ACCOUNT It: ASSIGNED TO: <br />107:Y./.S-SOR <br />PR 0: <br />'W-0S-4 /--7 4 <br />ACCOUNTING COMPLETED BY: <br />/I- <br />DATE: /.2 ./ <br />/ 7 / 7 k <br />2-6TC), 3 <br />9-3-2015 <br />Site Mitigation MFR 29- <br />LLn Z3 70)