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cm STOCKTON STATE CA ZIP 95215 <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: THIRD PARTY BILLING[Z] FACiLITY/BusINESSD OWNERD <br />ATTENTION: ORCARE OF (0P770N4L) BUSINESS NAME ADVANCED GEOENVIRONMENTAL, INC. <br />PHONE (209)467-1006 MAIUNG ADDRESS 837 SHAW ROAD <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH b=eARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FO <br />"MFR"- GREEN F ORM <br />r if ED <br />DATE <br />-- .day Li 1017 <br />SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK <br />LIWIRO <br />IF OWNER IS CLIMW a nt <br />PROPERTY <br />OWNER NAME <br />CHARLES SKOBRAK PHONE <br />(209)465-2667 FIRST MI LAST <br />BUSINESS NAME LARRYS AUTO REPAIR E-MAIL ADDRESS <br />OWNER HOME ADDRESS 947 EAST HIGHWAY 26 ATTENTION: OR CARE OF (OPTIONAL) <br />Cm STOCKTON STATE CA ZIP 95215 <br />OWNER MAILING ADDRESS 947 EAST HIGHWAY 26 <br />MAILING ADDRESS CITY 947 EAST HIGHWAY 26 STATE CA ZiP 95215 <br />0 CORPORATION <br /> 0 INDIVIDUAL <br /> El PARTNERSHIP LI GOVERNMENT AG5NçY 1:1 RESPONSIBLE PARTY <br /> <br />0 OTHER <br />. ENVIRONMENTAL III EHD LOCAL VOLUNTARY <br />CLEANUP <br />2953 <br />. RWQCB LEAD— WQCE LEAD— ivi:j1r. DTSC LEAD <br />2959 <br />FED EPA LEAD <br />2954 ASSESSMENT <br />2950 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />R QUALITY (WDR) <br />2965 <br />.1 I. <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 IN <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES 0 No D <br />BUSINESS/FACILITY/SITE/PROJECT NAME LARRY'S AUTO REPAIR APN: <br />SITE ADDRESS / PROJECT LOCATION 308 NORTH GRANT STREET BUSINESS PHONE <br />Crrf STOCKTON STATE CA ZIP 95202 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE Kerl KEY2 <br />MAIUNG ADDRESS, IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />SIC CODE COMMENT: <br />THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, <br />or Responsible Party and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated <br />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 <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 <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 representative. <br />APPLICANT NAME (PLEASE PRINT) RENE TOTH <br /> <br />SIGNATURE <br /> <br />TrTLE STAFF GEOLOGIST <br /> <br />TAX ID# <br /> <br />FA #:-.ACO <br />FA 30 6 .2.A ' <br />OWNER ID #: 014/602/5-0 ACCOUNT #:7W0,42goci ASSIGNED TO: <br />PR #: pRos-q-io pi- ACCOUNTING COMPLETED BY: i ,/ <br />tit <br />DATE: /2-6 17 <br />9-3-2015 <br />Site Mitigation MFR 29-