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PHONE 209-467-1006 MAIUNG ADDRESS 837 Shaw Road <br />BUSINESS NAME Advanced GeoEnvironmental Inc. ArrernoN Daniel Villanueva <br />CITY Stockton STATE CA ZIP 95215 EMAIL . dvtllanueva@advgeoenv.com <br />I ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br /> <br />OWNER0 <br /> <br />FACILITY/BUSINESSO <br /> <br />REQUESTORM <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 04/11/2018 SHADED AREAS FOR END USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OISWER IS CURRENTLY ON FILE WITH END <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 ROME ADDRESS 435 North Harrison Street ATTENTION: ORCARE OF (OPT/OW.40 <br />CITY Stockton STATE GA Zip 95203 <br />OWNER MAI UNG ADDRESS same as home address <br />MAILING ADDRESS CITY STATE ZIP <br />LI CORPORATION El INDIVIDUAL 0 PARTNERSHIP 0 GOVERNMENT AGENCY IN RESPONSIBLE PARTY El CroiER <br />ENVIRONMENTAL END LocAL VOLUNTARY RWQCB LEAD— RWQCB LEAD— 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? <br />IS THIS AN EXISTING PROJ ECT LOCATION, BUT A NEW SCOPE OF WORK? <br />YES TJ No 0 <br />YES El No in <br />BUSINESSNACIUTY/SITE/PROJECT NAME Dominics Auto Tech APN 137-250-060 <br />SITE ADDRESS i PROJECT LOCATION 435 North Harrison Street BUSINESS PHONE 209-762-2753 <br />crry Stockton STATE CA ZIP 95203 <br />BOARD OF SUPERVISOR DISTRICT LLOCATION CODE KerI Ker2 <br />MAILING ADDRESS , IF DIFFERENT FROM FACIUTY AOORESS same as facility address <br />MAILING ADDRESS CITY STATE ZIP <br />SIC Corm COMMENT: <br />REOUESTOR7 S INFORMATION: <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 <br />information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all <br />applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the <br />undersigned Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby <br />authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is/pr ided or my representative. <br />APPLICANT NAME (PLEASE PRINT) Daniel J. Villanueva SiONATUREI - <br />TITLE Senior Geologist <br /> TAxio# <br />PA l: OWNER 10 It: ACCOUNT g: ASSIGNED TO: <br />PR I: 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 2-26-2018