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SAN AQUIN COUNTY ENVIRONMENTAL HEALTh ..PARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER Is CURRENTLY ON FILE WITH END <br />PROPERTY <br />OWNER NAME <br />DICKIE GUTHRIE PHONE <br />c Qs; MI LAS7 <br />BUSINESS NAME J & D AUTO E-MAIL ADDRESS <br /> <br />OWNER HOME ADDRESS 1011 SOUTH CHEROKEE LANE ATTENTION: ORCARE OF (oinvouti) <br />Cm LODI STATE CA ZIP 95240 <br />OWNER MAILING ADDRESS 1011 SOUTH CHEROKEE LANE <br />MAILING ADDRESS CfTY LODI STATE CA LP 95240 <br />CORPORATION <br />INDNIDUAL <br /> El PARTNERSHIP <br /> <br />0 GOVERNMENT AGENCY 6 RESPONSIBLE PARTY <br /> <br />0 OTHER <br />LX7, ENVIRONMENTAL • EHD LOCAL VOLUNTARY RWQCB LEAD- RWQCB LEAD- DTSC LEAD <br />2959 <br />E FED EPA LEAD <br />2954 <br />ASSESSMENT CLEANUP <br />2950 I 2953 i <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />FACILITY FILE: COMPLETE BUSINESS! SITE/ PROJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? <br /> <br />YES EN <br />No E <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? <br />YES E <br />No ti;) <br />BUSINESS/FACILITY/SITE/PROJECT NAME J & D AUTO <br />APN: 047-400-07 <br />SITE ADDRESS! PROJECT LOCATION 1011 SOUTH CHEROKEE LANE <br /> BUSINESS PHONE <br />Orr( LODI <br />STATE CA ZIA 95240 <br />BOARD OF SUPERVISOR DISTRICT I LOCATION CODE I- I KEY1 1 ! Ker2 <br />MAIUNG ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS <br />MAIUNG ADDRESS CRY <br />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 <br />ATTENTION: ORCARE OF (OP77ON4L.) <br />IAAJUNG ADDRESS <br />PHONE <br />CITY <br />STATE zw <br />1 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br />OWNERO <br /> <br />FACILITY/BUSINESS <br /> <br />THIRD PARTY BILUNGO <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 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 repfsentative. <br />1/yytn <br />TITLE Otott Met-r-v Ot_43 <br />Tax ID IS <br />" <br />FAN: FA 00.24tiac <br />t <br />/ OWNER' <br />ID II. 0111)602.3 007 <br />ACCOUNT #: ,7,6--c,- c <br />-)4o I <br />, <br />ASSIGNED TO: <br />PR #: ?pos_.42..ce)7 ACCOUNTING COMPLETED BY: <br />. 7-02 <br />DATE: <br />1 <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 />$456.00 <br />$76000 '/1i iic((--61 6 ig i <br />Site Mitioation MFR 2p- XXX P-1 .7n1 7 <br />APPLICANT NAME (PLEASE PRINT) Art VIC4-FC Z4 Vb'' VV SIGNATURE