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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE TMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 29 JUNE 2018 SHADED AREAS FOR EHD USE <br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OiVNER Is CLIRRENTIV ON PILE WITH EHD X <br />PROPERTY <br />OWNER NAME <br />MIN LE PHONE (408) 893-1418 <br />FIRST MI LAST <br />BuspiEssNAmE MCBILLIN REAL ESTATE INVESTMENT E-MAIL ADDRESS <br />OWNER HOME ADDRESS 3087 OLDWOOD COURT ATTENTION: OR CARE OF (OPTIONAL) <br />crry SAN JOSE STATE CA ZIP 95122 <br />OWNER MAILING ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />0 CORPORATION <br /> <br />0 INDIVIDUAL <br /> <br />M PARTNERSHIP <br /> <br />0 GOVERNMENT AGENCY 0 RESPONSIBLE PARTY <br /> <br />0 OTHER <br />In ENVIRONMENTAL . EHD LOCAL VOLUNTARY 0 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 />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 0 No K] <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF Wow? YES 0 No LK <br />BUSINESS/FACluran-E/PRoJEcT NAME MCBILLIN PROPERTY APN 167-060-010-000 <br />SITE ADDRESS / PROJECT LOCATION 2154 SOUTH EL DORADO STREET BUSINESS PHONE <br />Cirr STOCKTON STATE CA ZIP 95206 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE Keel Ker2 <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 <br /> <br />ATTENTION <br /> <br />mmuNGADDREss 837 SHAW RD <br /> <br />PHONE (209) 467-1006 <br /> <br />crrr STOCKTON STATE CA ZIP 95215 EMAIL erottacker@advgeoenv corn <br /> <br />AccouNT ADDRESS To SEND FEES AND CHARGES: <br /> <br />OWNERD <br /> <br />FACILITYIBUSINESSD <br /> <br />REQUESTORM <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 HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />APPUCANT NAME (PLEASE PRINT) ERIN ROTTACKER SIGNATURE <br /> r-k- L <br />TITLE STAFF GEOLOGIST <br /> <br />TAX ID* <br /> <br />FA #: r 7-1 I OWNER ID #: Nel0.25t4ff ACCOUNT #: m6647104+7 ASSIGNED TO: <br />PR #: WD51713 4,42 _2_ ACCOUNTING COMPLETED BY: DATE: / /71 <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 I" r t ‘.., (, <br />i - " — - 2( 8 / A-j i'''—e0 7' i &11 <br />Site Mitigation MFR 2-26-2018