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PHONE (209) 467-1006 MAILING ADDRESS 837 SHAW ROAD <br />BUSINESS NAME ADVANCED GEOENVIRONMENTAL, INC ATTENTION: ORCARE OF (OPTIONAL) <br />Car STOCKTON STATE CA LP 95215 <br />I <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: <br /> <br />OWNER LI <br /> <br />FACILITY/BUSINESSEI <br /> <br />THIRD PARTY BILLING[ <br />SAN JO' '!IN COUNTY ENVIRONMENTAL HEALTH PcPARTMENT <br />SITE MITIG,,i1ON MASTER FILE RECORD INFOk ATION FORM <br />"MFR"- GREEN FORM <br />DATE 08 February 2018 SHADED AREAS FOR EHD USE <br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD <br />PROPERTY <br />OWNER NAME <br />PHONE (209) 467-1006 <br />FIRST MI LAST <br />BUSINESS NAME JH Simpson Co. Inc. E-MAIL ADDRESS <br /> <br />OWNER HOME ADDRESS 4025 Coronado Avenue ATTENTION: ORCARE OF (OPTIONAL) <br />OrTy Stockton STATE CA ZIP 95204 <br />OWNER MAILING ADDRESS 4025 Coronado Avenue <br />MAILING ADDRESS CITY Stockton STATE CA LP 95204 <br />El CORPORATION <br /> I=1 INDIVIDUAL 8 PARTNERSHIP <br /> <br />El GOVERNMENT AGENCY D RESPONSIBLE PARTY <br /> <br />El OTHER <br />al ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />I EHD LOCAL VOLUNTARY RWQCB LEAD - RWQCB LEAD - <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />IN 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 El No 0 <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES 0 No M <br />BusiNEWFAciuryiSiTE/PRoJEcr NAME JH Simpson Co. Inc. APN: 115-300-25 <br />SITE ADDRESS/ PROJECT LOCATION 1 01-1 a _ _ _t. t , _ . .. l i i BUSINESS PHONE <br />CM LODI STATE CA im 95240 <br />BOARD OF SUPERVISOR DISTRICT I LOCATION CODE Merl Kra <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: 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,4iepresentati <br />Toth APPLICANT NAME (PLEASE PRINT) Rene M. SIGNATURE <br />Tax ID TITLE STAFF GEOLOGIST <br />FA #: ---- A <br />- t ' /1.002 .4 I t tt.)7 OWNER ID #: ACCOUNT #: AA4^)-173 <br />ASSIGNED TO: <br />PR #: Pgcs IL-20-/-7 ACCOUNTING COMPLETED BY: (ip DATE: <br /> <br />SR TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECVD BY DATE SERVICE REQUEST# INVOICE# <br />Work Plan <br />2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 <br />_ , L ,+.. '‘,4. .1 , ,, —CL —IJ; h•L <br />Site Mitigation MFR 29- XXX 8-1-2017