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g/Ar oA E <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FinCEIVED <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Lci ,ARTME <br />"MFR"- GREEN FORM <br />DATE 08/01/2017 <br />..."0 II ci [Ulf <br />SHADED AREAS FOR EHD USE <br />ENV1R <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK <br />NMENTA <br />IF OWNER Ififterlyrttetriti <br />S PHONE 209482-3191 PROPERTY <br />OWNER NAME <br />Mr. Jim and Karen Weber <br />FIRST MI LAST <br />Busmen Nan VACANT PROPERTY— FORMER REPAIR SHOP E-MAIL ADDRESS <br />OWNER HOME ADDRESS : 2229 MANZANITA COURT ATTENTION: ORCARE OF (OPTIOM4L) <br />C" LODI STATE CA ziP 95242 <br />OWNER MAILING ADDRESS SAME <br />MAILING ADDRESS CITY STATE ZiP <br /> <br />CORPORATION <br /> 12:1 INDIVIDUAL <br /> 13 PARTNERSHIP <br /> <br />0 GOVERNMENT AGENCY D RESPONSIBLE PARTY <br /> 0 OTHER <br />ENVIRONMENTAL EHD LOCAL VOLUNTARY 0 RWQCB LEAD- RWOCB LEAD- E DTSC LEAD <br />2959 ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />FED EPA LEAD <br />2954 <br />FACILITY FILE: COMPLETE BUSINESS! SITE/ PROJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? <br />IS THIS AN EXISTING PROJECT LOCATION. BUT A NEW SCOPE OF WORK? <br />YES 0 No CE <br />YES El No 0 <br />BU8INESSIFACILITY/SITE1PROJECT NAME Vacant Property APN: 043-023-01 <br />SrrE ADDRESS / PROJECT LocA-nom 230 NORTH CHURCH STREET BUSINESS PHONE <br />cal' Lodi STATE CA ZIP 95240 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 Kea <br />MAIUNG ADDRESS , IF DIFFERENT FROM FACIUTY ADDRESS : 2229 MANZANITA COURT <br />MAILING ADDRESS CRY: L odi STATE CA zip: 95240 <br />SIC CODE Comma: <br />THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />BUSINESS NAME Mr. Jim and Karen Weber ATTENTION: ORCAREOF (OPTIONAL) KAREN WEBER <br />, <br />MAIUNG ADDRESS 2229 MANZANITA COURT PHONE 209-482-3191 <br />CRY LODI STATE CA ziP 95240 <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNERS FACILITY/BUSINESS 0 THIRD PARTY BILLING!: <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, or <br />Responsible Party and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with <br />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 <br />provided on this application is true and correct; and 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 Owner, <br />Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby authorize the release of <br />any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />APPLICANT NAME (PLEASE PRINT) WILLIAM LITTLE <br />SIGNATURE <br />TIME GEOLOGIST-AGENT <br /> TAx ID# 1.11 <br />FA #: FA(:40747, OWNER ID #: 010(00 ....._._ ACCOUNT #: 4R,11/43 ASSIGNED TO: <br />PRIA: .MO(CeeeXc30I- <br />ACCOUNTING COMPLETED BY: DATE: /7/f.7 <br />Work Plan <br />SR TYPE PE <br />2903 <br />2904 <br />Sc <br />523 <br />523 <br />FEE INFO AMT REMITTED CHECK# REM) BY <br />(-6 <br />$456.00 <br />$760.00 <br />SERVICE REQUE.ST# <br /> <br />INVOICE# <br />00 7)&7 <br />Site Mitigation MFR 29- XXX 8-1-2017