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Perm/mew 0 Oovermatorr mercy 0 Rforotants PANTY OTHIE 0 ComOMATION boorrouat. <br />EHD LocAL VoLuNrARY <br />CumuP <br />2963 <br />FACILITY FILE: COMPLETE BUSINESS / SITE/ PROJECT ITWORMATION: <br /> <br />RINOCIS LEAD— 0 MOM LEAD— I ,..., <br />LI MSC LEAD <br /> <br />Ac-noN WATER OuAurr (VVDR) 2969 <br />296W352613527 i 2966 <br />Fan EPA LEAD <br />2954 <br />o EMARONMENTAL <br />AssEssiaerr <br />2950 <br />STATE Zr <br />REDO E STOWS INFORMATION: <br />CrrY STATE CA Rn Vasa <br />Sueeens Plum <br />Woodward Dittirn Co. Inc. <br />Kama Admen 550 R000r Rood <br />wrfnmewoadvarddrihrp com Eiam. <br />Arrownom <br />Woodward <br />Nom <br />707-374-4300 <br />I ZIP 64571 <br />Mums Amman Crry <br />SICOooi Coseasert <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ReCjavED <br />2079 <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR"- GREEN FORM MAR 01 <br />3/01/2019 efigfttiD USE <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: &ma rayon is CumownyeellarsMIAND <br />Nom <br />209-937-7569 <br />Po:worry <br />Omen Noma <br />6410A.ADONE111 <br />Amenda.Thornamaslocklonce.gov INUNNIINI Na <br />Oman Nome Aceallee Anomie ORCARIOr formai) <br />City of Stockton - Economic Develovment Department <br />ETATS ZIP OrrY <br />OVRIMI MONO AMMO 400 E Main Street, 4th Floor <br /> <br />STATE <br />CA 95202 <br /> <br />aluurusAoonara CrY <br />Stockton <br />H THIS A NEW PECUEoT LOCATION ijia Piervo0uALY IMOULATOO BY THE EmARONMiNTAL HEALTH Onpoommorr? Ws El No 2 <br />Is THI8 AN DORM PROM= LOCATION, BUT A NEVI SCOPE OF WORK? <br /> <br />YES 0 No CI <br />ElomessA4FacturriSrreflormarn Nam <br />Arra Mims, i Papa= Lammas <br />310 W Fremont SOW (Fonnorty 424 Von Boron St) <br />ern, <br />Stockton <br />Rome oF SUPINAION Dterecr <br />/Ammo Atoms . Werytmarr peon Faraury Amines <br />PAWED FAcurriBusaaEssEl <br /> <br />REOUESTONgJ <br />BILLING AND C'ONIPI IANCE ACKNOWI FDGMFNT: 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 JOAQL I \ C HUN-TY <br />ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my repr <br />AppuQuirtsmis "we moil Wayne Woodward Sm.&ni 7 - 7 <br />APN <br />137-410-020 <br />Busmen ham <br />ETAT! Zw <br />CA 95203 <br />Km2 I <br />I ACCOUNT ADORERS To sow FEES AND CHASIMIM <br />Trrts Pnnapiel <br /> <br />TAX ma <br /> <br />Mg: r.7.4,a7.52s-/ 3 / OWNE110Ik 0/U0 62,37 ... A000UNTat A:x:47224 AMON= TCC <br />PM* 'pRas-v-12_,/y- AOCOUNTINE GOUPUITED EV1 4 / <br />orac 3/tef <br />SERVICE REQUEsi SR TYPE PE SC FEE INFO ANT REMITTED CHECK/ REM BY DATE INVOICES <br />2903 <br />2904 <br />523 <br />523 Wort Flan 45L $456.00 <br />$750.00 , S-S ILk 1.--)4 1 15-1 (1 5 k o l--0 7 gc <br />Site Mitigation PARR 2-26-2018