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ift RECEIVED SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FOrRIVI <br />"MFR"- GREEN FORM JUL 0 3 2018 <br />DATE 7/3/18 cilviTgerdttlEftADR EHD USE <br />ENT <br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD <br />PROPERTY <br />OWNER NAME <br />Sheldon Doss PHONE <br />707-974-4456 <br />FIRST MI LAST <br />BUSINESS NAME Doss Trucking E-MAIL ADDRESS <br />sdoss@dosstrucking.com <br />OWNER HOME ADDRESS 3775 Brickway Boulevard, Unit 100 ATTENTION: ORCARE OF (OPTIONAL) <br />Crre Santa Rosa STATE CA ZIP 95403 <br />OWNER MAILING ADDRESS Same as above <br />MAIUNG ADDRESS CITY STATE ZIP <br />:1 CORPORATION <br /> <br />I=1 INDIVIDUAL <br /> <br />El PARTNERSHIP <br /> <br />I=1 GOVERNMENT AGENCY al RESPONSIBLE PARTY <br /> <br />El OTHER <br />II ENVIRONMENTAL 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 (NDR) <br />2965 <br />. 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? <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? <br />YES 12 No 0 <br />YES 0 No 12 <br />BUSINESS/FACILITY/SITE/PROJECT NAME 1021 East Hazelton Avenue APN 151-280-030 <br />SITE ADDRESS / PROJECT LOCATION 1021 East Hazelton Avenue BUSINESS PHONE 510-410-1009 <br />Crry Stockton STATE CA ZIP 95203 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE Kerl Ker2 <br />MAILING ADDRESS, IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />SIC CODE COMMENT: <br />REQUESTOR'S INFORMATION: <br /> <br />BUSINESS NAME Partner ESI <br /> <br />ATTENTION Joe Mangine <br /> <br />MAIUNG ADDRESS 1017 22nd Avenue, Suite 107 <br /> <br />PHONE 510-410-1009 <br /> <br />Crry Oakland STATE CA ZIP 94606 Ewa. jmangine@partneresi.com <br /> <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br /> <br />OWNERD <br /> <br />FACILITY/BUSINESS al <br /> <br />REQUESTORD <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 />ENVIRONMENTAL DEALT!! DEPARTMENT as soon as it is available and at the same time it is pr ed to me or my representative. <br />APPLICANT NAME (PLEASE PRINT) Joe Mang me <br /> <br />SIGNATURE <br /> <br />TITLE Project Manager / Partner ESI <br /> <br />TAX ID ti <br /> <br />ril I <br />OWNER ID S: 0 LOOD 23 33 F ACCOUNT S: ASSIGNED TO: <br />ACCOUNTING COMPLETED BY: <br />19 <br />DATE: 7 // 7 <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUES # INVOICE# <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 $ 451, 3030g111 L —Y 701 I g Si-o0 li 31, I <br />Site Mitigation MFR 2-26-2018