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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br /> "MFR"-GREEN FORM <br /> DATE December 28, 2020 SHADED AREAS FOR END USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION. CN&VK IF OWNER IS OURRENTL Y ON FIL E wI rsr EHD❑ <br /> PROPERTY Art I I O'Brian PHONE 209.937.8460 <br /> OWNER NAME I FiRST I M1 I LAST <br /> BUSINESSNAME City of Stockton, Municipal Utilities Department E-MAIL ADDRESS <br /> OWNER HOME ADDRESS ATTENTION:OR CARE OF(OPTIaNAL) <br /> CITY STATE zw <br /> OWNER MAILING ADDRESS 2500 Navy Drive <br /> MAILING ADDRESS CITY Stockton STATE CA zw 95206 <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHtP GDVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> ❑ ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWOCB LEAD- 0 RWQCB LEAD- El DTSC LEAD ❑FED EPA LEAD <br /> ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2954 <br /> 2950 2953 296013526/3527 2965 <br /> FACILITY FILE:COMPLETE BUSINESS 1 SITE/PROJECT INFORMATION: <br /> IS THISA NEW PROJ ECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No M <br /> IS THIS AN EKISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑■ NO ❑ <br /> BuslNEss►FACiLITY1S1TErPROJECT NAME City of Stockton, Municipal Utilities Department APN 163-330-030-000 <br /> SITE ADDRESS I PROJECT LOCATION 2500 Navy Drive BUSINESSPHONE 209.937.8460 <br /> CITE' Stockton STATE CA zip 95206 <br /> BOARD OF SUPERVISOR DISTRICT LGCATHNI CODE Keyll KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS <br /> MAILING ADDRESS CITY STATE zip <br /> SIC CODE COMMENT: <br /> REQUESTOR'S INFORMATION: <br /> BUSiNESSNAME Kleinfelder, Inc. ATT6mom Jose J. Asyn <br /> MAILINGADDREss 2001 Arch-Airport Road, Suite 100 PHONE 209.327.0998 <br /> CITY Stockton STATE CA zip 95206 EMAIL JAsyn@kleinfelder.com <br /> ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNER❑ FAC ILITYIBU SI N ESSi] REQU ESTOR 0 <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,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 Parry 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 /> ?�} <br /> APPLICANT NAME(PLEASE PRINT] Jose J. Asyn SIGNATURE <br /> TITLE Principal TAxID# 94-1532513 <br /> FA N: OWNER ID#: ACCOUNT#: ASSIGNED TO: <br /> PR#: ACCOUNTING COMPLETED BY: DATE: <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> VVork Plan 2903 523 $456.00 <br /> 2904 523 $760.00 <br /> Site Mitigation MFR 2-26-2018 <br />