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SAN JOAnIlIN COUNTY ENVIRONMENTAL HEALTH DFPARTMENT <br />SITE MITIG. ON MASTER FILE RECORD INFOR. TION FORM <br />"MFR"- GREEN FORM <br />DATE 13 June 2018 SHADED AREAS FOR EHD USE <br />I OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK F OWNER IS CURRENTLY ON FILE WITH EHD <br />PROPERTY <br />OWNER NAME <br />Juen Lee PHONE <br />(209)467-1006 FIRST MI LAST <br />BUSINESS NAME E-MAIL ADDRESS <br />OWNER HOME ADDRESS 11699 Birchville Road ATTENTION: ORCARE OF (OPT/O/VAL) Juen Lee <br />CITY Nevada City STATE CA Zip 95959 <br />OWNER MAILING ADDRESS 11699 Birchville Road <br />zIP MAILING ADDRESS CITY Nevada City STATE CA 95959 <br />IR CORPORATION <br /> <br />El INDIVIDUAL <br /> <br />[1] PARTNERSHIP <br /> <br />GOVERNMENT AGENCY RESPONSIBLE PARTY <br /> <br />OTHER <br />F ENVIRONMENTAL END LOCAL VOLUNTARY RWQCB LEAD— RWQCB LEAD — <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (VVOR) <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 D No N <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES X No El <br />BUSINESS/FACILITY/SITE/PROJECT NAME Lee Properties - Hunter Street APN 139-060-230 <br />SITE ADDRESS / PROJECT LOCATION 540 North Hunter Street BUSINESS PHONE <br />CITY Stockton STATE <br />CA <br />ZIP 95202 <br />BOARD OF SUPERVISOR DISTRICT 1 LOCATION CODE KEY1 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 ATTENTION Advanced GeoEnvironmental Rene Toth <br />MAILING ADDRESS 837 Shaw Road PHONE (209)467-1006 <br />CITY Stockton STATE CA ZIP 95215 EMAIL Rtoth@advgeoenv.com <br />I ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br /> <br />OWNERD <br /> <br />FACILITY/BUSINESSO <br /> <br />REQUESTORU <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, <br />or Responsible Parry 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 i pro ided to me o presentative. <br />APPLICANT NAME (PLEASE PRINT) Rene Toth <br /> <br />SIGNATURE <br />TITLE Staff Geologist <br /> <br />TAX ID# <br /> <br />FA #: rj cl-_-)a _L t ,34- OWNER ID #: D O02321 ACCOUNT #: <br />• <br />.2_ ASSIGNED TO: <br />PR #: ?Rt)sq 4. <br />1 <br />ACCOUNTING COMPLETED SY: DATE: / fi <br />I <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 1 A L <br />Site Mitigation MFR 2-26-2018