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SAN J1. .11IN COUNTY ENVIRONMENTAL HEALTH ARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 06/14/2017 SHADED AREAS FOR EHD USE <br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON PILE WITH EHD Li <br />PROPERTY <br />OWNER NAME <br />PHONE <br />209-948-0302 FIRST MI LAST <br />BUSINESS NAME WEST CLAY PROPERTY (KRC) E-MAIL ADDRESS STEVE AZEVEDO@KNIFERIVER COM <br />OWNER HOME ADDRESS 639 WEST CLAY STREET ATTENTION: ORCARE OF (OPTIONAL) <br />CITY STATE CA ZIP 95209 STOCKTON <br />OWNER MAILING ADDRESS SAME AS ABOVE <br />MAILING ADDRESS CITY SAME AS ABOVE STATE ZIP <br />D CORPORATION <br /> <br />0 INDIVIDUAL 0 PARTNERSHIP <br /> <br />0 GOVERNMENT AGENCY RESPONSIBLE PARTY <br /> <br />0 OTHER <br />. ENVIRONMENTAL . EHD LOCAL VOLUNTARY 1151 RWQCB LEAD - M RWQCB LEAD - <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (WDR) <br />2965 <br />. DTSC LEAD . 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 12I <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES E No 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME WEST CLAY PROPERTY APN: 147-071-10 <br />SITE ADDRESS I PROJECT LOCATION 639 WEST CLAY ST BUSINESS PHONE 209-948-0302 <br />CITY STOCKTON STATE CA ZIP 95209 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE Keil _ Kea <br />MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS CITY STATE ZIP <br />SIC CODE 1 COMMENT: <br />THIRD PARTY BILLING INFO: COMPLETE IF BILLING P . ARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />BUSINESS NAME ADVANCED GEOENVIRONMENTAL, INC. ATTENTION: ORCARE OF (OPTIONAL) C/0 TIM CUELLAR <br />MAILING ADDRESS 837 SHAW ROAD PHONE 209-467-1006 <br />CITY STOCKTON STATE CA ZIP 95215 <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNERD FACILITY/BUSINESSO THIRD PARTY BILLINGD <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that lam 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 />40;17 eMdk—, <br />TITLE PROJECT MANAGER <br /> <br />TAX ID # <br />APPLICANT NAME (PLEASE PRINT) TIMOTHY J. CUELLAR SIGNATURE <br />FA 0: .., <br />bil 00 2 in / 5 <br />OWNER ID <br />ISO: MY-)2-2Ia" (3 3 arD4iE <br />ACCOUNT 1: <br />14440 i <br />ASSIGNED TO: <br />PR #: <br />-rie-laS),0 ) --- S- <br />ACCOUNTING COMPLETED BY: (ff DATE: <br />9-3-2015 <br />Site Mitigation MFR 29-