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ATTENTION Daniel Villanueva BUSINESS NAME Advanced GeoEnvironmental, Inc. <br />PHONE (209)467-1006 MAILING ADDRESS 837 Shaw Road <br />CITY Stockton STATE CA ZIP 95215 EmAllvillanueva©advgeoenv.com <br />I <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br /> <br />OWNERD <br /> <br />FACILITY/BUSINESSO <br /> <br />REQUESTORU <br />SAN J01- 1N COUNTY ENVIRONMENTAL HEALTH DE ,TMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 11 January 2019 SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER /3 CURRENTLY ON FILE WITH EHD <br />PROPERTY <br />OWNER NAME <br />Abelino and Decia Valdez PHONE <br />(209)833-7387 <br />FIRST MI LAST <br />( <br />BUSINESS NAME Jules Veterinary Center <br />E-MAIL ADDRESS <br />OWNER NOME ADDRESS ATTENTION: ORCARE OF (0PRON4L) <br />28065 Blossom Lane <br />CITY Tracy STATE CA ZIP 95304-8122 <br />OWNER MAILING ADDRESS same as above <br />MAILING ADDRESS CITY STATE ZIP <br />LI CORPORATION <br /> IR INDIVIDUAL <br /> LI PARTNERSHIP <br /> LI GOVERNMENT AGENCY LI RESPONSIBLE PARTY <br /> LI OTHER <br />RWQCB LEAD - M ENVIRONMENTAL EHD LOCAL VOLUNTARY RWQCB LEAD - MI DTSC LEAD FED EPA LEAD <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 2959 2954 <br />ILITY FILE: COMPLETE BUSINESS! SITE/ PROJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES KI No 0 <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES 0 No & <br />BUSINESS/FACILITY/SITE/PROJECT NAME Valdez Property APN 232-170-270 <br />Arl' SITE ADDRESS / PROJECT LOCATION 1755 West PAZda Street BUSINESS PHONE <br />ciTY—Steeitierr- -1-Petep_ STATE <br />CA <br />ZIP 95376 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE Keel Keil <br />MAILING ADDRESS, IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />SIC CODE COMMENT: <br />REQUESTOR'S INFORMATION: <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 pji4d to me or my representative. <br />APPUCANT NAME (PLEASE PRINT) Daniel Villanueva SIGNATURE <br />TITLE Senior Geologist <br /> <br />TAX ID# <br /> <br />FA #: F-A oe) 25-2 )41,10 OWNER ID #: D kk.,6 ACCOUNT #: A p...06 +70+ ASSIGNED TO: <br />PR #: pRils-A_fifroill <br />A Alr - <br />.0 <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 95140 -1 L'l Ill'-ii s (2-00 s'ooci 1 <br />Site Mitigation MFR 2-26-2018