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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION MASTER FILE RECORD INFORMATION FORM -"MFR"- GREEN FORM DATE 5/17 /2 0 2 4 SHADED AREAS FOR EHD USE OWNER FILE : COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IFOwNERisCURREAnYONFJLEwtw EHD PROPERTY Earl Wilson PHONE OWNER NAME FIRST Ml LAST BUSINESS NAME E-MAILADDRESS earl@stocktonrubber.com OWNER HOME ADDRESS 5023 North Floor Road ATTENTION:ORCARE OF(OPTPOAAL) CITY Linden STATE CA ZIP 95236 OWNER MAILING ADDRESS 5023 North Floor Road MAILING ADDRESS CITY Linden STATE CA ZIP 95236 ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER ® ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD- ❑ RWQCB LEAD- ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) ❑ DTSC LEAD I] FED EPA LEAD 2959 2954 2950 2953 2960/3526/3527 2965 FACILITY FILE: COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS ANEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ® No ❑ IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES ❑ No BUSINEss/FACILmr/SITE/PROJEcT NAME tb (, l�^^ R u y�Jy� A — Ls P PO r. � �A ` APN 10517032 & 10517033 SITE ADDRESS/PROJECT LOCATION 5023 North D/\ Floor Road BUSINESS PHONE CITY Linden STATE CA ZIP el BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEYZ �O MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS MAILING ADDRESS CITY STATE ZIP SIC CODE COMMENT: REQUESTOR'S INFORMATION: BUSINESS NAME partner Engineering & Science, Inc . TA;r NTIoN Michel Helou MAILING ADDRE88 4 9 0 4 3 r d Street PHONE 7 7 4-414-3 6 6 6 CITY Oakland STATE CA —7ZIP 94 609 EMAILmhelou@partneresi . com ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ REQUESTOR® BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, 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 HOURLY CHARGES associated 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 provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. APPLICANT NAME(PLEASE PRINT) Michel H e l o u SIGNATURE TITLE Project Manager TAXID# FAQ: 'I OWNER IDM ACCOUNTM ASSIGNED TO: PR#: FACCOUNTING COMPLETED BY: DATE: SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV-D BY DATE SERVICE REQUEST# INVOICE# Work Plan 2903 523 $486.00 _ A , 2904 523 $810.00 ' C L v �� Site Mitigation MFR 7-01-2023 M- (� f f r Au to' V'0 S rCc 1. 1