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STATE CA ZIP 95215 CITY STOCKTON <br />THIRD PARTY BILLINGEl ACCOUNT ADDRESS TO SEND FEES AND CHARGES: FACILITY/BUSINESSEI OWNER!: <br />ATTENTION: ORCARE OF (OPTIONAL) BUSINESS NAME ADVANCED GEOENVIRONMENTAL <br />MAILING ADDRESS 837 SHAW ROAD PHONE 209-467-1006 <br />SAN JOAO' IIN COUNTY ENVIRONMENTAL HEALTH DPPARTMENT <br />SITE MITIG, JN MASTER FILE RECORD INFORL ;ION FORM <br />"MFR"- GREEN FORM <br />DATE 28 March 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 />Roberto Merlos PHONE <br />209-762-2753 FIRST MI LAST <br />BUSINESS NAME DOMINIC'S AUTO TECH E-MAIL ADDRESS <br />OWNER HOME ADDRESS 435 NORTH HARRISON STREET ATTENTION: ORCARE OF (OPTIONAL) <br />CITY STOCKTON STATE CA ZIP 95203 <br />OWNER MAILING ADDRESS SAME AS HOME ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />0 CORPORATION <br /> <br />0 INDIVIDUAL <br /> CI PARTNERSHIP <br /> <br />0 GOVERNMENT AGENCY El RESPONSIBLE PARTY <br /> <br />0 OTHER <br />ENVIRONMENTAL M EHD LOCAL VOLUNTARY RWQCB LEAD - RWQCB LEAD - M DTSC LEAD FED EPA LEAD <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 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 CI No El <br />BUSINESS/FACILITY/SITE/PROJECT NAME DOMINIC'S AUTO TECH APN: 137-250-060 <br />SITE ADDRESS! PROJECT LOCATION 435 NORTH HARRISON STREET BUSINESS PHONE 209-762-2753 <br />CITY STOCKTON, CA STATE ZIP 95203 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br />MAILING ADDRESS 435 NORTH HARRISON STREET <br />MAILING ADDRESS CITY STOCKTON STATE ZIP 95203 <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, or <br />Responsible Party and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with <br />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 REcuLA rioNs. 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 res ye. <br />APPLICANT NAME (PLEASE PRINT) DANIEL VILLANUEVA SIGNATUR <br /> <br />TITLE SENIOR PROJECT GEOLOGIST <br /> <br />TAX ID # <br /> <br />FA #: F-7400.zy - OWNER ID #: 0(.1)6023 i s-3 ACCOUNT #: 74/2...aDy.5-Egly ASSIGNED TO: <br />PR #: ACCOUNTING COMPLETED BY: (le) DATE: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECYD BY DATE SERVICE REQUE T# INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 • t , Ifli,olVe 21 r-001 kctio-i <br />Site Mitigation MFR 29- XXX 8-1-2017