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MAILING ADDRESS 837 SHAW ROAD PHONE (209) 467-1006 <br />BUSINESS NAME ADVANCED GEOENVIRONMENTAL, INC ATTENTION: ORCARE OF (OPTIONAL) <br />SANS QUIN COUNTY ENVIRONMENTAL HEALTH 3ARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM <br />DATE 12 FEBRUARY 2018 SHADED AREAS FOR EHD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD <br />PROPERTY <br />OWNER NAME <br />DAVE GUARDINO PHONE (209) 948-1636 <br />FiRS' MI LAST <br />BUSINESS NAME GUARDINO AND CRAVVFORD CONSTRUCTION E-MAIL ADDRESS <br />OWNER HOME ADDRESS 517 WEST FREMONT STREET ATTENTION: ORCARE OF (0P770NAL) <br />crry STOCKTON STATE CA ZIP 95203 <br />OWNER MAILING ADDRESS 517 WEST FREMONT STREET <br />MAILING ADDRESS CITY STOCKTON STATE CA ZIP 95203 <br />D CORPORATION <br /> LI INDIVIDUAL <br /> LI PARTNERSHIP <br /> <br />111 GOVERNMENT AGENCY [X RESPONSIBLE PARTY <br /> D OTHER <br />. ENVIRONMENTAL . EHD LOCAL VOLUNTARY III RWQCB LEAD - 0 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 IIIII 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 [XI <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES [g] No 0 <br />BUSINESS/FACILITY/SITE/PROJECT NAME GUARDINO AND CRAVVFORD CONSTRUCTION APN: 137-214-10 <br />SITE ADDRESS /PROJECT LOCATION 517 WEST FREMONT STREET BUSINESS PHONE <br />Cm STOCKTON STATE CA ZIP 95203 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 Kea <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 />CrrY <br /> STOCKTON <br /> <br />STATE CA <br /> <br />ZIP 95215 <br /> <br />ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br /> <br />OWNERO <br /> <br />FACIUTYIBUSINESSO <br /> <br />THIRD PARTY BILLINGIN <br /> <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 iiipreseptativri <br />APPLIC.ANT MANE (PLEASE PRINT) ERIN ROTTACKER SIGNATURE <br />6L/ At) <br />Trni STAFF GEOLOGIST TAX 10# <br />FA #: <br />PR' Wzos,i-3-s-g3 <br />OWNER ID #: <br />ACCOUNTING COMPLETED BY: ze4g2 <br />0A1002-2-01 ACCOUNT #: 420,D13 <br />DATE: <br />ASSIGNED TO: <br />PE SC SR TYPE FEE INFO AMT REMITTED CHECIO RECV'D BY DATE SERVICE REQUEST# INVOICE# <br />2903 <br />2904 <br />523 <br />523 <br />$456.00 <br />$760.00 isi(0 ac) Work Plan <br />Site Mitigation MFR 29- XXX 8-1-2017