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PHONE MAILING ADDRESS <br />837 Shaw Road <br />CITY 95215 Stockton STATE CA ZIP <br />THIRD PARTY BILLINGIX ACCOUNT ADDRESS To SEND FEES AND CHARGES: FACILITY/BUSINESSE OWNERD <br />ATTENTION: ORCARE OF (OPTIONAL) BUSINESS NAME Advanced GeoEnvironmental, Inc. (AGE) <br />SAN JO" '11IN COUNTY ENVIRONMENTAL HEALTH r—DARTMENT <br />SITE ION MASTER FILE RECORD INFOF,...ATION FORM <br />"MFR"- GREEN FORM <br />DATE SHADED AREAS FOR END 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 />Guardino Crawford, CO - Dave Guardino PHONE <br />(209) 601-4169 FIRST MI LAST <br />BUSINESS NAME Guardino & Crawford E-MAIL ADDRESS kathid@live.com <br />OWNER HOME ADDRESS 517 West Fremont Street ATTENTION: ORCARE OF (OPTIONAL) <br />Crry Stockton STATE CA ZIP 95203 <br />OWNER MAILING ADDRESS PO Box 1689 <br />MAILING ADDRESS CITY Stockton STATE CA ZIP 95201 <br />a CORPORATION <br /> <br />INDIVIDUAL <br /> 0 PARTNERSHIP <br /> E GOVERNMENT AGENCY <br /> 0 RESPONSIBLE PARTY <br /> 0 OTHER <br />. ENVIRONMENTAL . EHD LOCAL VOLUNTARY I2[ RWQCB LEAD— <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />. RWQCB LEAD— <br />ASSESSMENT <br />2950 <br />CLEANUP <br />2953 <br />WATER QUALITY (WDR) <br />2965 <br />MI DISC LEAD E 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 13 <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES IA No E <br />BUSINESS/FACILITY/SITE/PROJECT NAME Guardino & Crawford APN: 137-214-10 <br />SITE ADDRESS! PROJECT LOCATION 517 West Fremont Street BUSINESS PHONE <br />(209) 601-4169 <br />CITY Stockton CA <br />STATE ZIP 95203 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE _ KEY1 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 />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 />HEALTI I DEPARTMENT as soon as it is available and at the same time it is provided to me or my reprsentati.ve. <br />APPLICANT NAME (PLEASE PRINT) Brian Millman SIGNATURE <br /> <br />TITLE Project Geologist <br /> <br />TAX ID # <br /> <br />FA #: <br />r/I DO) 3 T.2.__ <br />OWNER ID #: <br />"'UJD,r)2-2---6)1 <br />ACCOUNT #:A <br />NrD,111-35i () <br />ASSIGNED TO: <br />PR #: <br />-PRaS-Li-13c1--L- <br />ACCOUNTING COMPLETED BY: (162 DATE: <br />e- tb <br />9-3-2015 <br />Site Mitigation MFR 29-