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SAN JO ' IIN COUNTY ENVIRONMENTAL HEALTH I-- 'ARTMENT <br />SITE MITIG,-., ION MASTER FILE RECORD INFOR. .ATION FORM <br />"MFR"- GREEN FORM <br />DATE May 31, 2017 SHADED AREAS FOR EHD USE <br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER 18 CURRENTLY ON FILE WITH EHD <br />PROPERTY <br />OWNER NAME <br />Lori Shields PHONE (209) 946-0233 <br />FIRST MI LAST <br />BUSINESS NAME Diesel Performance Inc. E-MAIL ADDRESS <br />OWNER HOME ADDRESS ATTENTION: ORCARE OF (OPTIONAL) <br />CITY STATE ZIP <br />OWNER MAILING ADDRESS 2804 East Fremont Street <br />MAILING ADDRESS CITY Stockton STATE CA zll' 95205 <br />M CORPORATION <br /> I: INDIVIDUAL <br /> I: PARTNERSHIP <br /> I: GOVERNMENT AGENCY 1: RESPONSIBLE PARTY <br /> 0 OTHER <br />ICI ENVIRONMENTAL IIII END LOCAL VOLUNTARY MI RWQCB LEAD- E RWQCB LEAD- <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />IIII DTSC LEAD IIII 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 IX No I: <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES I: No El <br />BusINEssiFAcimy/SITEJPRoJEcT NAME Diesel Performance Inc. APN: 143-430-08 & 143-430-61 <br />SITE ADDRESS! PROJECT LOCATION 2804 East Fremont Street BUSINESS PHONE <br />CITY Stockton STATE CA ZIP 95205 <br />BOARD OF SUPERVISOR DISTRICT 1 LOCATION CODE I Kell KEY2 <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 PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />BUSINESS NAME ATC Group Services LLC <br /> <br />ATTENTION: OR CARE OF (OPTTONAL) <br />Jeanne Homsey <br /> <br />MAILING ADDRESS 1117 Lone Palm Avenue, Suite 201B <br /> <br />PHONE (209) 579-2221 <br />Cry Modesto <br /> STATE CA ZIP 95351 <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: <br /> <br />OWNER': <br /> <br />FACILITY/BUSINESS': <br /> <br />THIRD PARTY BILLING[ <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) <br /> <br />SIGNATURE <br /> <br />-lienot <br />TAx ID *1 <br /> TITLE <br />FA #: <br />6 0.2 ,1-2s gr OWNER ID M O 14/6021.5-17 ACCOUNT #: ASSIGNED TO: heone.74.74.5__ <br />PR #: <br />a 7 4 Keo5-(1-) ACCOUNTING COMPLETED BY: a, DATE: <br />9-3-2015 <br />Site Mitigation MFR 29-