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APN: 163-230-34 BUSINESSIFACILITY/SITE/PROJECT NAME JM EQUIPMENT COMPANY <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? <br /> <br />YES El <br /> <br />No 1E1 <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? <br />YES El <br /> <br />No 0 <br />SITE ADDRESS PROJECT LOCATION 1245W. CHARTER WAY BUSINESS PHONE <br />CITY STOCKTON STATE CA ZIP 95201 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE Kul KEy2 <br />MAILING ADDRESS, IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADD RESS CITY STATE ZIP <br />SAN QUIN COUNTY ENVIRONMENTAL HEALT 7PARTMENT <br /> <br />SITE Mn ...IATION MASTER FILE RECORD INFOrciVIATION FO 11 RE), ti —WFD <br />"MFR"- GREEN FORM <br />8/9/17 <br />DATE il IA fal/ii EHD USE SHAkA_E_S <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS effinfivereftreR 4, i <br />PROPERTY <br />OWNER NAME <br />Georae Betk.er <br />PHONE 209-848-3PERMIT/SFRVICES 1 4 <br />FIRST MI LAST <br />BUSINESS NAME GEO PROPERTIES, INC. E-MAIL ADDRESS <br />OWNER HOME ADDRESS 2306 JACKIE CT. ATTENTION: ORCARE OF (OPTIONAL) <br />CITY OAKDALE STATE CA ZIP 95361 <br />OWNER MAILING ADDRESS SAME <br />MAILING ADDRESS CITY STATE ZIP <br />El CORPORAllON <br /> CI INDIVIDUAL <br /> Cl PARTNERSHIP 1:1 GOVERNMENT AGENCY <br /> 121 RESPONSIBLE PARTY <br /> 1=I OTHER <br />ENVIRONMENTAL II EHD LOCAL VOLUNTARY RWQCB LEAD— RWQCB LEAD— <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />WATER QUALITY (VVDR) <br />2965 <br />III DTSC LEAD FED EPA LEAD <br />2959 2954 <br />FACILITY FILE: COMPLETE BUSINESS! SITE/ PROJECT INFORMATION: <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 ATTENTION: ORCARE OF (OPTIOAL4L) <br />MAILING ADDRESS PHONE <br />Orr STATE ZIP <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: <br /> <br />OWNEREI <br /> <br />FACILITY/BUSINESSO <br /> <br />THIRD PARTY BILLINGO <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 <br />information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all <br />applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the <br />undersigned Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby <br />authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provid to me or my representat <br />APPLICANT NAME (PLEASE PRINT) GEORGE BETKER SIGNATURE", <br /> <br />TITLE VP <br /> <br />TAX1D # 77-0325291 <br /> <br />OWNER ID #: ")14/00 22 -7 4 i ACCOUNT #: A1 ay_45-07.... <br />2_, <br />ASSIGNED TO: I <br />j <br />PR #: ?R on_ 4220 ( _ ACCOUNTING COMPLETED BY: 7, k DATE: <br />SR TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE!! <br />Work Plan 2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760 00 9/15 Ct (31) 7 fi '-S-- <br />Site Mitigation MFR 29- XXX 8-1-2017