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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTRECEIVED <br />SITE MITIC ON MASTER FILE RECORD INFOF .TION FORM <br />Artl 2 "MFR"- GREEN FORM <br />DATE 13 April 2018 ENVIRCENMEIMIRWALIFOR EHD USE <br />PERMIT/SERW:FS <br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON RLE WITH EHD <br />PROPERTY <br />OWNER NAME <br />PHONE <br />(209)467-1006 FIRST MI LAST <br />BUSINESS NAME California Welding Supply <br />E-MAIL ADDRESS <br />OWNER HOME ADDRESS PO Box 567 ATTENTION: OR CARE OF feRROANO, Beverly Garcia <br />CRY Stockton STATE CA ZIP 95201 <br />OWNER MAILING ADDRESS PO Box 567 <br />MAIUNG ADDRESS CITY Stockton STATE CA ZIP 95201 <br />CORPORATION <br /> <br />INDIVIDUAL <br /> <br />1=1 PARTNERSHIP <br /> <br />GOVERNMENT AGENCY 1:1 RESPONSIBLE PARTY <br /> <br />OTHER <br />F ENVIRONMENTAL M EHD LOCAL VOLUNTARY 1.1 RWQCB LEAD- 1. RWQCB LEAD- <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />MI DTSC LEAD II 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 <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES <br />I No • <br />0 NO 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME California Welding Supply - Raymond Property <br />I APN 24-9-342.041r, <br />SITE ADDRESS / PROJECT LOCATION 817 South Center Street BUSINESS PHONE <br />CITY Stockton STATE <br />CA <br />ZIP 95206 <br />BOARD OF SUPERVISOR DISTRICT I LOCATION CODE Keil Kea <br />MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />SIC CODE COMMENT: <br />REQUESTOR/S INFORMATION: <br />BUSINESS NAME Advanced GeoEnvironmental ATTENTION Rene Toth <br />MAILING ADDRESS 837 Shaw Road PHONE (209)467-1006 <br />CITY Stockton STATE CA ZIP 95215 awl_ Rtoth@advgeoenv.com <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br /> OVVNERE <br /> FACILITY/BUSINESSO <br /> REQUESTORU <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 assessmen form oSkN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is proyktf to e my r a rsentative. <br />APPLICANT NAME (PLEASE PRINT) Rene Toth SIGNATURE <br />TITLE Staff Geologist <br /> Tax ID# <br />FA #: MOD.2.,b---72' OWNER ID #: 014 ky...)23/ .7 ,g_., ACCOUNT #: mco(i.c. (m.0 ASSIGNED TO: <br />PR 0 : 7,.... cG 11. 27 ,qt ACCOUNTING COMPLETED BY: de DATE: <br />SR TYPE TYPE PE SC FEE INFO AMT REMITTED CHECK# REM BY DATE SERVICE RECWEST# INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 1 k-Glo ).`i 0 irc L --)( LII/410 C g-W —lci °Zg <br />Site Mitigation MFR 2-26-2018