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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 02/22/18 <br />SHADED AREAS FOR END USE <br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNEW IS CURRENTLY ON INLE FINN EHD <br />PROPERTY <br />OWNER NAME <br />City of Stockton City of Stockton PHONE <br />FIRST MI Lasr <br />BUSINESS NAME City of Stockton - Economic Development Department EMAIL ADDRESS <br />OWNER HOME ADDRESS N/A Arremoti: ORCARE OF toeTtottAkt <br />CITY Stockton STATE CA Zir, 95202 <br />OWNER MAILING ADDRESS 400 E. Main Street, 4th Floor <br />MAILING ADDRESS Crry Stockton STATE CA bp 95202 <br />ILI CORPORATION El INDIVIDUAL 0 PARTNERSHIP 0 GOVERNMENT AGENCY N RESPONSIBLE PARTY 0 OTHER <br />0 ENVIRONMENTAL <br />ASSESSMENT <br />2950 <br />. EHD LOCAL VOLUNTARY El RWQCB LEAD— <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />E RWQCB LEAD- <br />WATER QUALITY (WDR) <br />2965 <br />FED EPA LEAD <br />2954 <br />CLEANUP <br />2953 <br />DTSC LEAD <br />2959 <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 0 NO N <br />YES N No D <br />BUSINESSIFACILITY/SITE1PROJECT NAME 424 N. Van Buren Street APN: 137 -410-02 <br />SITE ADDRESS / PROJECT LOCATION 310W. Fremont Street BUSINESS PHONE <br />CITY Stockton STATE CA ZIP 95202 <br />BOARD OF SUPERVISOR DISTRICT I LOCATION CODE KEY1 _ Key2 <br />MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS 400 E. Main Street, 4th Floor <br />MAILING ADDRESS CITY Stockton, CA 95202 STATE ZIP <br />SIC CODE COMMENT: <br />_ <br />HIRD PARTY BILLING INFO GOMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> <br />BUSINESS NAME <br />ATTENTION: ORCARE OF (OPTIONAL) <br /> <br />MAILING ADDRESS <br />PHONE <br /> <br />CT' <br />STATE <br />ZIP <br /> <br />I <br /> <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNERD <br />FAciuTY/BUSiNESSO THIRD PARTY BILLINGE <br /> <br />BILLING .AND COMPLLkNCE 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, EiVFORCEMENT 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 s i e or my representative. <br />SIGNATURE APPLICANT NAME (PLEASE PRINT) 0 lpd( <br />This econornic be,AtiorevaIi- A00.47 s+ <br />TAX !DM <br />FAII: FA 00 2pp-112r OWNER ID IV 014)00,7307 i ACCOUNT*, Axs:40,74.57 4i:2_ ASSIGNED TO: <br />PR #: ?Itia9i-?5-el t 4 - <br />ACCOUNTING COMPLETED BY: zy, DATE: i /g• <br />SR TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECVD BY DATE SERVICE REQUE T# INVOICE# <br />Work Plan 2903 <br />I 2904 <br />523 <br />523 -3,7 <br />$456.00 <br />$760.00 55109 I - - X 3 j 1 I tx \ c-o oiS1-16 <br />Site Mitigation MFR 29- XXX 8-1-2017