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SAN JOA, COUNTY ENVIRONMENTAL HEALTH DE, ..ATMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 28 March 2019 SHADED AREAS FOR END USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD Lii <br />PROPERTY <br />OWNER NAME <br />Peter Navarra PHONE <br />(916)798-6161 FIRST MI LAST <br />BUSINESS NAME FtAS Car Wash and Detail Center <br />E-MAIL ADDRESS <br />OWNER HOME ADDRESS ATTENTION: ORCARE OF (OPT1ONAL) 3220 Northrop Avenue <br />CITY Sacramento STATE CA ZIP 95864 <br />OWNER MAILING ADDRESS same as above <br />MAIUNG ADDRESS CITY STATE ZIP <br />CI CORPORATION <br /> k INDIVIDUAL <br /> ID PARTNERSHIP <br /> D GOVERNMENT AGENCY D RESPONSIBLE PARTY <br /> <br />OTHER <br />IE3 ENVIRONMENTAL EHD LOCAL VOLUNTARY I III 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 />I 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 <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES <br />KI No D <br />D No k <br />235-173-200 and APN <br />735-173-040 <br />BUSINESS PHONE <br />BUSINESS/FACILITY/SITE/PROJECT NAME Navarra Family Properties <br />SITE ADDRESS / PROJECT LOCATION 108 and 128 East Eleventh <br />CITY Tracy STATE CA ZIP 95376 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYI KEY2 7 <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 Advanced GeoEnvironmental, Inc. <br /> <br />ATTENTION Daniel Villanueva <br /> <br />mmuNeA' 837 Shaw Road <br /> <br />PHONE (209)467-1006 <br /> <br />CITY Stockton STATE CA ZIP 95215 EmAtIvillanueva©advgeoenv.com <br /> <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: <br /> <br />OVVNERD <br /> <br />FACILITY/BUSINESSD <br /> <br />REQUESTORW <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 provide me ative. <br />APPUCANT NAME (PLEASE PRINT) Daniel Villanueva SIGNATURE <br />TITLE Senior Geologist <br /> <br />TAX ID* <br /> <br />FA #: X2.57 ge2-- OWNER 10 II: Z) woe) 23 gs—e:„ ACCOUNT 0: •.4,(.7L737/ ASSIGNED TO: <br />PR #: ?R.D5 4 130E ACCOUNTING COMPLETED BY: 7,19 DATE: <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 LKlo ?, ) L- Ai 4 11 1 V1 5 iz-oogoLt 11 <br />Site Mitigation MFR 2-26-2018