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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION MASTER FILE RECORD INFORMATION FORM "MFR"-GREEN FORM DATE I January 29, 2019 SHADED AREAS FOR EHD USE OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CnwitirOwmwisCuwwenrzravrruwrnr EHD E1 PROPERTY Garry Duncan PHONE OWNER NAME FtRST Sr (209)937-8309 BUSINESS NAME City of Stockton E L/IDDa Garry.duncan@stocktonca.go OWNER HOME ADDRESS 425 N. EI Dorado Street ATTENTION:omCARE OF(opnoNAL) Cm Stockton FATE CA ZIP 95206 OWNER MAILING ADDRESS As Above MAiuNGADORESSC1TY STATE zip ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER AF If ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD— ❑ RWQCB LEAD— ❑ DTSC LEAD ❑FED EPA LEAD ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2954 2950 2953 2960/352613527 2965 FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES W No ❑ BUSINESSIFACILITYISREIPROJECTNAME STAND Affordable Housing APN 163-010-000& 169-151-010-000 SITE ADDRESS IPRo,,EcTLOcAnON 2222&2244 S. Airport Way BUSINESS PHONE (209)466-3568 CITY Stockton STATE CA Zip 95206 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS MAILING ADDRESS CITY STATE zip SIC CODE 11 COMMENT: REQUESTOR'S INFORMATION: BUSINESS NAME ATTENTION MAILING ADDRESS 1 I, (, yE.. PHONE q q 'l CITY M J T* STATE zip 1 S b EMAIL C r ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER[:) FACILITY/BUSINESS❑ REQUESTORD-- BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that 1 am the Owner,Operator,Authorized Agent, or Responsible Party and I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated 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 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, I 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 provjde yd W.me or in representative. APPLICANT NAME(PLEASE PRINT) V �_ r J �.. �. SIGNATURE l . TITLE > 1 y _ TAX IDS �]L L' � � � 7 J FA I: OWNER ID/: 1 )/�/� p71 ACCOUNT/: D D? - ASSIGNED TO: PRI: �nO Z l ACCOUNTING OO�wLerEO Sr. so I OV /�L�lDATE: 3 SRTYPE PE SC FEE INFO AMT REMITTED CHECK# RECYD BY DATE SERVICE REQUEST INVOICE# Work Plan 2903 523 $456.00 2904 523 $760.00 List Site Mitigation MFR 2-26-2018