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0 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP GOVERNMENT AGENCY <br />ENVIROMYIENTAL <br />ASSESSMENT <br />2950 <br />RWQCB LEAD - <br />CORRECTIVE ACTION <br />2960/3526/3527 <br />EHD LOCAL VOLUNTARY <br />CLEANUP <br />2953 <br />0 DTSC LEAD <br />2959 <br />BusiNEss/FAciLnytthTFJPRoJEcT NAME <br />Waterloo Food and Fuel <br />SrrE ADDRESS! PROJECT LOCATION <br />3032 Waterloo Rd <br />No rig <br />No p <br />YES El <br />YES (8:1 <br />BOARD OF SUPERVISOR DISTRICT LOCAllON CODE I KEYI <br />Apex Envirotech, Inc BUSINESS NAME <br />0 OTHER <br />FACILITY FILE: COMPLETE BUSINESS / SITE/ PROJECT INFORMATION: <br />RESPONSIBLE PARTY <br />0 FED EPA LEAD <br />2954 <br />RWQCB LEAD- <br />WATER QUALITY (WDR) <br />2965 <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? <br />I APN 1 43-1 40-300-000 <br />BUSINESS PHONE (209) 466-5816 <br />STATE CA ZIP 95205 <br />KEy2 <br />MAIUNG ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS <br />MAILING ADDRESS CITY <br />STATE ZiP <br />IColima: <br />REQUESTOR'S INFORMATION: <br />SIC CODE <br />11291 Pyrites Way, Suite B <br />Gold River STATE CA <br />MAILING ADDRESS <br />Crry <br />ATTENTION Bryan McCarthy <br />PHONE (916) 851-0174 <br />ZIP 95670 EMAIL bmccarthy@apexenvirotech.com <br />Stockton <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE MITIGATION MASTER FILE RECORD INFORMATION FORM <br />"MFR" - <br />DATE 8/5/2021 <br />.... . - .....•.-_,-... • ......,,, <br />SHADED AREAS FOR EHD USE <br />OWNER FILE: <br />PROPERTY <br />COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD a <br />OWNER NAME <br />Deputy s Dhaliwal PHONE <br />(206) 292-8175 FIRST MI LAST <br />BUSINESS NAME Waterloo Food and Fuel E-MAIL ADDRESS <br />OWNER HOME ADDRESS 1 South Grady Way ArrENTioN: ORCARE Of (OPT/04) <br />CITY Renton <br />STATE WA ZJP 98057 <br />OWNER MAILING ADDRESS 1 South Grady Way <br />MAIU NG ADDRESS CITY Renton <br />STATE WA ZiP 98057 <br />1 <br />BILL ANC. tin Crvynn T A ive.v ACKNOWLEDGMENT: the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, or Responsible Party and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or 110URLY CHARGES associated with this project will be billed to me at the address identified above as the ACCOUAT 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 CouNry <br />ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />SR3NATURE <br />tig V <br />TAX ID# <br />FA #: <br />F A007130 <br />#: <br />#: OWNER ID <br />0W0017560 I Am:Him-it: AR0038592 ASSIGNED TO: .1W <br />PR <br />pRIlzi -1711_8 ACCOUNTING COMPLETED BY: DATE: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE SERVICE REQUEST# INVOICE# <br />Work Plan 2903 <br />2904 <br />523 (13.2) 456 Cc ,fi ‘,, ' 8/24/2021 ,00841 3 8 523 $760.00 <br />AccouNr ADDRESS To SEND FEES AND CHARGES: OWNERO FACILITY/BUSINESSO REOUESTOREI <br />1 <br />APPLICANT NAME (PLEAsE PRINT) apiA 4 c k,;.,/,-„,v/1-\- <br />TrTLE <br />e111 <br />on Irma ton um er. IiUuuu i '_ ite Mitigation MFR 2-26-2018