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MAILING ADDRESS 837 SHAW ROAD PHONE (209) 467-1006 <br />BUSINESS NAME ADVANCED GEOENVIRONMENTAL, INC ATTENTION: ORCARE OF (OPTIONAL) <br />SAN JIN COUNTY ENVIRONMENTAL HEALTH I RTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION 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 />OWNER HOME ADDRESS 4025 Coronado Avenue ATTENTION: ORCARE OF (OPTIONAL) <br />CITY Stockton STATE CA ZIP 95204 <br />OWNER MAILING ADDRESS 4025 Coronado Avenue <br />MAILING ADDRESS Crrf Stockton STATE CA ZIP 95204 <br />CORPOFtATION <br /> 0 INDIVIDUAL IN PARTNERSHIP <br /> 0 GOVERNMENT AGENCY 0 RESPONSIBLE PARTY <br /> 0 OTHER <br />XI ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />M EHD LOCAL VOLUNTARY M RWQCB LEAD— . RWQCB LEAD— <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />M 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 [2:1 No 0 <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES 0 No ffl <br />BUSINESS/FACILITY/SITE/PROJECT NAME JH Simpson Co. Inc. APN: 115-300-25 <br />SITE ADDRESS! PROJECT LOCATION 4025 Coronado Avenue BUSINESS PHONE <br />CITY Stockton STATE CA ZIP 95204 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br />MAIUNG ADDRESS. IF DIFFERENT FROM FACILITY ADDRESS <br />MAIUNG 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 />STOCKTON <br /> <br />STATE CA <br /> <br />ZIP 95215 <br /> <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br /> <br />OWNER': <br /> <br />FACILITYIBUSINESSO <br /> <br />THIRD PARTY BILLING[ <br /> <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 representative. <br />Toth APPLICANT NAME (PLEASE PRINT) Rene M. SIGNATURE <br />TRU STAFF GEOLOGIST <br /> <br />TAX ID # <br /> <br />FA #: OWNER ID #: ACCOUNT #: ASSIGNED TO: <br />PR #: ACCOUNTING COMPLETED BY: DATE: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE SERVICE REQUEST# INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 <br />Site Mitigation MFR 29- XXX 8-1-2017