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SAN JG-41.11N COUNTY ENVIRONMENTAL HEALTH Gam. ARTMENT SITE MITIGATION MASTER FILE RECORD INFORMATION FORM "MFR"-GREEN FORM DATE October 27, 2017 SHADED AREAS FOR EHD USE OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECKIFOWNER/S CURRENTLYONFILewiTH EHD E1 PROPERTY Garry Ducan PHONE OWNER NAME I FiRsT M1 LAST 209-937-8309 BUSINESS NAME E-MAIL ADDRESS CITY OF STOCKTON Garry. Ducan(cDStocktonca. ov OWNER HOME ADDRESS 425 N EI Dorado St ATTENTION:OR CARE OF(OPTIONAL) CITY Stockton STATE CA zip 95202 OWNER MAILING ADDRESS same as-aboy-e-- MAILING ADDRESS CITY STATE zip ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP R1 GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER ® ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD- ❑ RWQCB LEAD- ❑ DTSC LEAD ❑FED EPA LEAD ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2954 2950 2953 29601352613527 2965 FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES (ja No ❑ IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No M BUSINESSIFACILI Y/SITEIPROJECT NAME Airport Way Development APN: 169-163-01 & 169-151-01 SITE ADDRESS I PROJECT LOCATION 2222 & 2244 S. Airport Way BUSINESS PHONE 209 466-3568 CITY Stockton CA 95202 STATE zip BOARD OF SUPERVISOR DISTRICT11 1 LOCATION CODE KEY1 KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS MAILING ADDRESS CITY STATE zip SIC CODE COMMENT: THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME ATTENTION:ORCARE OF (OPTIONAL) MAILING ADDRESS PHONE CITY STATE zip ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER® FACILITY/BUSINESS❑ THIRD PARTY BILLING❑ BILLING AND COMPLIANCE AcKNOYI LEDGNIF.,,T: I, the undersigned Applicant, certify that I am the Owner, Operator,Authori.ed Agent, or Responsible Parr), and I acknowledge that all PERAUT FEES,PEAALTms,E.vFORCEmENT CHARGES and/or HoURL F CHARGES associated with this project will be billed to me at the address identified above as the ACCOuwTADDRESS 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 FEDER:\L Laws and RF,CULATIONS. As the undersigned Owner, Operator, Authorized Agent, or Responsible Pm4v for the project located above under facility/site address, I hereby authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONNIENTAI. HEALTH D[:PARUNIENT as soon as it is available and at the same time it is provided to me or my resentati APPLICANT NAME(PLEASE PRINT) SIGNATUREAll TITLE ( r �B TAX LD# FA#: ,�^ 7� OWNER ID# � ACCOUNT#: �n ASSIGNED TO: PR#: ` , ACCOUNTING COMPLETED BY: DATE: // G 9-3-2015 J r sz- 1st r 7 3 "7 0 Site Mitigation MFR 29-