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SAN JIOUIN COUNTY ENVIRONMENTAL HEALTH L•ARrMENT <br /> DATE /r2 l]1MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> I SITE MITIGATION & LOP <br /> 11ADEEAREAa FOKEHDU!l ONLY OWNER IDR OMEN UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: EHDEl <br /> PROPERTOMERNAME Maria & Christian Zamorano (209)470-3905 <br /> FIRST MI Lnsr PHONE NUMSER <br /> BUSINESS NAME E MAIL ADDRESS <br /> chis73 ahoo.com <br /> OWNER HOME ADDRESS 2114 Aztec Avenue <br /> CITY GAzip <br /> Stockton CA 95206 <br /> OWNER MAIUW ADDRESS 2114 Aztec Avenue <br /> MAIuw ADORESSCrrY Stockton STATE7j' 95206 <br /> CA <br /> ❑CORPORATION ICI INDMDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONMeu PARTY ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP WATER QUALITY NW PIPELINE INVESTIGATION LOP <br /> FACILITY IDR INV# ACCOUNT ID P ROR ASSKiNED EMPLOYEE LEAD AGENCY:EHD_RWQCB-X—OTSC_EPA_ <br /> Z/Cfty 1 13-2018Os3G71g Jo(-rNvy <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPORTMENT? YES ❑ No IX <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES No ❑ <br /> BErs.%nWFACtLRYISITFJPAoJEOr NAME Former Siebold Construction Co. <br /> SREADDRESSIPRQIlCTLoCATION 820 S. American Street SurnI BUSINESS PHONE <br /> CITY Stockton STATE CA zip 95206 <br /> SMRDOFSUPERVIRORDRTRICT / LDDATTONCODE j KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OYTACI <br /> MAILING ADDRESS CITY STATE LP <br /> SIC CODE APNR /�{7 n ^� COWAMr: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY.] IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME GHD Inc. ATTENTION:ORCARE OF(OPICAME) <br /> MAILING ADDRESS 2235 Mercury Way, Suite 150 PHONE (707) 523-1010 <br /> Crtr Santa Rosa STATE CA nP 95407 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILTfY/BUSINESS❑ THIRD PARTY BILLING <br /> IS <br /> BILLING AND COMPLIANCE A KNOW EDGMENT: I,the undersigned Applicant,Certify that I am the(Mier,Opemoor.AIRROIK[d AFenl.Or Reiianniffe Pao,and I acknomiedge that all P£RAIRF£ER. <br /> PENALn£R,ExR)RCEAR?NECRAROEY and/or Ef()URLYCRARG£.e associated with this project will be billed to me at the address identified above ns the ACCOUNTADDR£CC for this site. 1 also certify dmt ell <br /> information provided on this application is"a and correct;and tht all regulated activities will be performed In accordance with all applicable SAN JOAQVIN COUNTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or F1:DERAL Laws alai REGULATIONS. As DIe undersigned(Avner,Operator,ADthorRed Agent,err Responsible Party for the project locited ehme under facility/site address,I <br /> hereby allthorvR the release Of any and all resWM,reports,and Adler environmental assessment information to SAN JOAQUIN COUNTY ENVI ENTAL IJEALTH DEPARTMENT as soon as it is available <br /> and at the same time it is prmided to me or my representative. <br /> APPU WI%aMe(PLEASEPINNr) Ryan Crawford SICNATURE <br /> �-7 <br /> nTLe Project Geologist rAxlD# 98-0425935 <br /> APPROVED BY I DATE ADDDG"NO OFFICE PROCESSING COMPLETED BY DATE <br /> SITE III AMOUNT PAID DATE OF PAYMENT PAWENTTYPE RECEIPTS CHECK# REcEWID BY WORK <br /> FEE:$ (�=�( <br />