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San Jbwquin County Environmental Health bnoartment <br /> DATE11 0721 2014 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE'.COMPLETETHEFOLLOW/NG PROPERTY OWNER/NFORMATiow CHECKrF OWN ERCURRENTLYONFILE WITH E H D El <br /> PROPERTY OWNER NA-E:[: JOHN FERRIAOLO (20P 931-2700 <br /> First MI Last PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> former HARRY'S AUTO MART <br /> Owner Home Address <br /> PO BOX 757 <br /> City STATE LP <br /> LODI JUL 2I 2014 1 CA 195241 <br /> Owner Mailing Address <br /> same as above <br /> Mailing Address City PERMIT/SERVICE$ state Zip <br /> CORPORATION❑ INDIVIDUAL® PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP X <br /> FACILIrr ID# INV# AccouNT ID PR//#/RO# # s <br /> FACILITY FILE COMPLETE THEFOLLoW/NG BUSINESS/FACILITY/SITE/NFoRMATrom <br /> Is this a NEW Business LOCATION not previously regulated by the ENv;RoNMENTAL HEALTH DEPARTMENT? YES ❑ No El <br /> Is this an ExisTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No 91 <br /> BUSINESs/FAciuTY/SITE NAME <br /> former HARRY'S AUTO MART <br /> SITE ADDRESS SURE# BUSINESS PHONE <br /> 2662 N.Wilson Way <br /> CITY STATE ZIP <br /> Stockton CA 95205 <br /> SOARDOFSIIPERVISOROIS.'T I d/ LOCATION.CODE / KEY1 FK-2 <br /> Mailing Address ifD1FFERENT from Fac!/ityAddress Attention:orCare Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE Affta/ - <br /> COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of(optional) <br /> Advanced GeoEnvironmental Inc. <br /> Mailing Address PHONE <br /> 837 Shaw Road 800-511-9300 <br /> CITY STATE ZIP <br /> Stockton CA 95215 <br /> Aaa2u&TAUOBEsg for fees and charges OWNER FACILITY/BUSINESS HIRD PARTY BILLIN <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PER,m FEES, <br /> PENALrms,ENFORCEMENT CHARGEs and/or HOURLY CHARGES associated with this Operation will be billed to me at the address Identified above as the ACcouNTAnDREss 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 applicable SAN JOAQUINCOUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time It is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) WILLIAM LITTLE SIGNATURE , <br /> TITLE TAX ID# <br /> GEOLOGIST 68-0354606 <br /> Approved By Date ACcounting Office Processing Completed By Date ! <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPTII CHECK# RECEIVED BY WORK PLAN l' w <br /> FEE:*/ <br /> 3sZIG <br />