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SAN COQ"'IIN COUNTY ENVIRONMENTAL HEALTH r— 'ARTMENT <br /> SITE MITIG. __.ON MASTER FILE RECORD INFOR, __.TION FORM <br /> "MFR"-GREEN FORM <br /> DATE 3/19/2019 SHADED AREAS FOR EHD USE <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECKIFOWNERISCURRENTLYONFILEw?N EHD El <br /> PROPERTY Mary Martin PHONE <br /> OWNER NAME FiRST AST 209-608-4185 <br /> BUSINESS NAME A &A Transmission E-MAIL ADDRESS <br /> OWNER HOME ADDRESS 195 W Barstow Ave, Apt A ATTENTION:ORCARE OF(OPTIONAL) <br /> CITY Clovis STATE CA zip 93612 <br /> OWNER MAILING ADDRESS 195 W Barstow Ave, Apt A <br /> MAILING ADDRESS CITY Clovis STATE CA ZIP 93612 <br /> ❑CORPORATION X INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> ® ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD- ❑ RWQCB LEAD- ❑ 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/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ® No ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No <br /> BUSINESS/FACILITY/SITE/PROJECTNAME A &A Transmission APN 151-350-06 <br /> SITE ADDRESS/PROJECT LOCATION 1211 South Wilson Way BUSINESS PHONE <br /> CITY Stockton STATE CAZIP 95205 <br /> BOARD OF SUPERVISOR DISTRICT 11 LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE COMMENT: <br /> REQUESTOR°S INFORMATION: <br /> BUSINESS NAME Green Environmental Management ATTENTION Lita Freeman <br /> MAILINGADDRESS 5098 Foothills Blvd, Suite 3-146 PHONE 916-677-9897 <br /> CITY Roseville I <br /> STATE CA zIP 95747 EMIALlfreeman@green-em.com <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ REQUESTORN <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that 1 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 COUNT <br /> ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) Lita Freeman, P.G. SIGNATURE .ice <br /> TITLE Environmental Professional TAX ID# 3.3-�oi217�(0 <br /> FA M rA0:1 L,/ OWNER ID#: O <br /> ZW )Zf G ACCOUNT M ASSIGNED TO: <br /> PR M �Jn� � ACCOUNTING COMPLETED BY: D DATE. 3 I A <br /> SR TYPEPE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# ` / INVOICE# <br /> Work Plan 2903 523 $456.00 <br /> 2904 523 $760.00 It y 131 $ O b Z <br /> Site Mitigation MFR 2-26-2018 <br />