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• <br />SAN _QUIN COUNTY ENVIRONMENTAL HEALTH r'ARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 07/31/2017 SHADED AREAS FOR END USE <br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD n <br />PROPERTY <br />OWNER NAME <br />Mr. Jim Weber and Mrs. Karen Weber PHONE <br />209-482-3191 <br />FIPST MI LAST <br />BUSINESS NAME Vacant property - former Cain Electrical E-MAIL ADDRESS <br />OWNER HOME ADDRESS 2229 Manzanita Court ATTENTION: ORCARE OF (OPTIONAL) <br />Cm( Lodi, California, 95242 STATE ZIP <br />OWNER MAILING ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />0 CORPORATION <br /> E INDIVIDUAL <br /> LIJ PARTNERSHIP 0 GOVERNMENT AGENCY 0RESPONSIBLE PARTY <br /> <br />OTHER <br />III ENVIRONMENTAL II EHD LOCAL VOLUNTARY II RWQCB LEAD— I RWQCB LEAD— <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />M DTSC LEAD I FED EPA LEAD <br />2959 2954 <br />FACILITY FILE: COMPLETE BUSINESS! SITE/ PROJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES 0 No g <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES 6 No LI <br />BusiNEss/FAciLny/SITE/PRoJEcT NAME Vacant property - former Cain Electrical APN: 043-023-01 <br />SITE ADDRESS! PROJECT LOCATION BUSINESS 230 North Church Street, Lodi, California, 95240 PHONE <br />Div( STATE ZIP <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE _ KErl Kea <br />MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />SIC CODE COMMENT: <br />THIRD PARTY BILLING INFO: COMPLETE IF BILLING P . ARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> <br />BUSINESS NAME Mr. Jim Weber and Mrs. Karen Weber ATTENTION: OR CARE OF (0P770NAL) <br /> <br />MAILING ADDRESS 2229 Manzanita Court <br /> <br />PHONE <br /> <br />Crry Lodi, California, 95242 <br /> <br />STATE <br /> <br />Zip <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br /> <br />OWNERO <br /> <br />FACILITYIBUSINESSO <br /> <br />THIRD PARTY BILLING ( <br /> <br />BILLING AND CONIPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, <br />or Responsible Party and I acknowledge that all PEOHT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated <br />with this project will be billed to me at the addressa • entified above as the ACCOUNT ADDRESS for this site. I also certify that all information r <br />provided on this application is true and correct; , d that all regulated activities will be performed in accordance with all applicable SAN <br />JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned <br />Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby authorize the <br />release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br />HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my repres$ative. <br />, William Little APPLICANT NAME (PLEASE PRINT, <br />TITLE <br /> <br />Agent for permit <br />SIGNATURE <br />TAX ID # <br />FA #: OWNER ID #: ACCOUNT #: ASSIGNED TO: <br />PR 0: ACCOUNTING COMPLETED BY: DATE: <br />9-3-2015 <br />Site Mitigation MFR 29-