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DATE <br />' <br />E'IV ViRegfic) ED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK <br />P "PE rilk IF OWNER 1.9434_ ...LY MD X <br />PROPERTY <br />OWNER NAME <br />Christian & Maria Zamorano, et al V ICES <br />PHONE <br />209-470-3905 FIRST MI LAST <br />BUSINESS NAME E-MAIL ADDRESS <br />z.rpallets@outlook.com <br />OWNER HOME ADDRESS 2114 Aztec Ave ATTENTION: ORCARE OF (OPTIONAL) <br />CITY Stockton STATE CA zip 95206 <br />OWNER MAILING ADDRESS same <br />MAILING ADDRESS CITY STATE Zu. <br />CI CORPORATION CI INDIVIDUAL 171 PARTNERSHIP CI GOVERNMENT AGENCY 0 RESPONSIBLE PARTY El OTHER <br />ENVIRONMENTAL U EHD LOCAL VOLUNTARY RWQCB LEAD- 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? <br /> YES CI No 11 <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? <br /> YES No 1:1 <br />SAN JOAuUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMERECE1 <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM Vet) <br />"MFR"-GREEN FORM JUN <br />APN 147-292-090, -110 <br />SITE ADDRESS / PROJECT LOCATION 820 S. American Street BUSINESS PHONE <br />Cry Stockton STATE CA ZIP <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE Keil Kea <br />MAILING ADDRESS, IF DIFFERENT FROM FACILITY ADDRESS <br />BUSINESS/FACILITY/SITE/PROJECT NAME Siebold Construction <br />MAILING ADDRESS CITY STATE ZP <br />SIC CODE <br /> COMMENT: <br />REQUESTOR'S INFORMATION: <br /> <br />BUSINESS NAME Geocon, Inc. <br /> <br />ATTENTION Nicole Hastings-Bethel <br /> <br />MAILING ADDRESS 3160 Gold Valley Drive, #800 <br /> <br />PHONE 916-852-9118 <br /> <br />CITY Rancho Cordova STATE CA ZIP 95742 EMAIL hastings@geoconinc.com <br /> <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br /> OVVNERID <br /> <br />FACILITY/BUSINESSEI <br /> <br />REQUESTORE <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 <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 />i <br />TITLE c. I t <br />TAX ID # <br />ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provid/d to o ny repre ntative. <br />APPLICANT NAME (PLEASE PRINT) tjL \c S SIGNATURE <br />FA #: :1 4. (#β€˜31.1- OWNER ID #: ).4.) 00.43 3 4)2_ ACCOUNT #: 41.40e ASSIGNED TO: <br />PR <br />It: Z S-435-0 <br />ACCOUNTING COMPLETED BY: DATE 47.2,e3/75 <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# ' INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 '43XCAL, " C'' /24 i a S e--OD β€”ri 31.3 <br />Site Mitigation MFR 2-26-2018