SITE INFORMATION AND CORRESPONDENCE

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SAN JO%,.WIN COUNTY ENVIRONMENTAL HEALTH L,.,/ARTMENT DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM -11 SITE MITIGATION&LOP SHADED AREA"FOR EHD USE ONLY OWNER ID# CASE# UNIT IV OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTL V ON FILE W/rH EHD El PROPERTY OWNER NAME Victor �= Hernandes ( ) FIRST MI LAST PHONE NUMBER BUSINESS NAME Former Arrooyos Smog Shop E-MAIL ADDRESS OWNER HOME ADDRESS 4302 Boulder Creek Circle CITY Stockton STATE CA 7'P 95219 OWNER MAILING ADDRESS SAME MARING ADDRESS CITY STATE LP ❑CORPORATION ®INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONStBLE PARTY ❑OTHER SITE MITIGATION_ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP FACILITY 10# INV# ACCOUNT ID PR#/RO# ASSIGNED EMPLOYEE Eff EHD_RWQCB_DTSC_EPA_ FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No P IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES No ❑ BUSINEssWACILITY/SITE/PROJECTNAME Former Arroyos Smog SITE ADDRESS/PROJECT LOCATION 3012 East Waterloo Road SUITE# BUSINESS PHONE CIT" Stockton STATE CA ZIP 95205 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS 302 Boulder Creek Circle ATTENTION:OR CARE OF(OIPflO/WL) MAILING ADDRESSCm Stockton, SFJ STATEtA LP 95205 SIC CODE APN# 143-130-24 COMMENT: THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME Vincent Hernandez ATTENTION:ORCARE OF(opno ay MAILING ADDRESS 4302 Boulder Creek Circle PHONE 477-4362 C"Y Stockton STATE ca LP 95219 ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTYBILLING(X BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the(boner,Operator,Authorized Agent,or Responsible Party and I acknowledge that all PERMIT )FES, PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated With this project will be billed tome at the address identified above as the ACCOUNTADDRESS for this site. I also certify that all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operator,Authorized Agent,or Responsible Party for the project located above under facility/site address,l hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. APPLICANT NAME(PLEASE PRINT) Vincent Hernandez SIGNATURE TITLE Owner TAX ID# APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE FEE:;