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PHONE 707-748-7743 Malling Addre,s 1090 Adams Street, Suite K <br />YES I= <br />YES [Z] <br />No [Z] <br />No 0 <br />Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? <br />Is this an EXISTING Business LocKnoN but a NEW TYPE of regulated Business? <br />BUSINESS/FACILITY/SITE NAME Stockton Pharmacy <br />SITE ADDRESS SurrE BUSINESS PHONE 3310 & 3330 East Main Street <br />Stockton STATE ZIP <br />CA 95205 <br />Mailing Address IfD/FFERENT from Facility Address Attention: orCare Of (optional) <br />Mailing Address City STATE ZIP <br />SIC CODE COMMENT: APN - <br />P.) 7' f 0 -IC) <br />THIRD PARTY IhuuNa INFO CompleteffBilling Party isdifferentfromPropertyOwner orFacility Operator identified above. <br />BUSINESS NAME Gribi Associates Attention: orCare Of (opflenall Jim Gribi <br />BOARD OF SUPERVISOR DISTRICT / LOCATION CODE / KEY1 KEY2 <br />I <br />DATE August 15, 2012 <br />San J, 4uin County Environmental Health sartment <br />MASTER FILE RECORD INFORMATION "MFR" <br />OWNER IDS I <br /> <br />CASE SHADED AREAS FOR EHD USE ONLY <br />GREEN FORM <br />SITE MITIGATION & LOP <br />UNIT IV <br />OWNER FILE :COMPLETE ME FOLLOWING PROPERTY OWNER INFORMA770N: CHECK IF OWNER CURREFIrLY ON FILE WITH END <br />PRoomm OWNER NAM EH National Bank (951)232 -3077 <br />First MI Last PHONE NUMBER <br />BUSINESS NAME EH National Bank <br />E-MAIL ADDRESS <br />Owner Home Address <br />43385 Business Park Drive, Suite 200 <br />City Temecula STATE <br />CA <br />ZIP <br />92590 <br />Owner Mailing Address Same as above <br />Mailing Address City State Zip <br />CORPORATION 11 <br />INDIVIDUAL 0 <br /> <br />PARTNERSHIP 0 <br /> <br />FED AGENCY ID <br />OTHER 0 <br />SITE INTGATION ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP WATER QuauTv NW PIPEUNE INVESTIGATION LOP <br />FACILITY ID # INV# ACCOUNT ID PR *I RO 0 AssiGNED EMPLOYEE LEAD AGENCY: END FtWQCB DTSC EPA <br />; t-,-/, <br />FACILITY FILE COMPLETE THE FOLLOWING BUSINESS! FACILITY! SITE INFORMATION: <br />Benicia STATE CA <br /> <br />Zirs 94510 <br /> <br />ACOCK/MADDRESS for fees and charges OWNER <br /> <br />FACILITY/BUSINESS <br /> <br />THIRD PARTY BILLING <br /> <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: L the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and I acknowledge that all PERMIT FEES, <br />PENAL TIES, ENFORCEMENT CHARGES and/or 1101IRLY CHARGES associated with this operation will be billed tomcat the address identified above as the AccouNTADDREss for this site. I also certify that <br />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 <br />Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner, operator, or agent of the property located at the above facility/site hereby authorize the release of <br />any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D RTMENT as s a it i av ble and at the same time it is <br />provided to me or my representative. <br />APPLICANT NAME (PLEASE PRINT) James E. Gribi SIGNATURE f)6 4Ugq-3 <br />TITLE Sr. Geologist <br /> <br />TAX ID # <br /> <br />Approved By Data Accounting Mos Processing Completed By _A ' , <br />I Lv's, Date ' r) <br />-7. "7 <br />C \ (.../ <br />SITE MITIGATION <br />FEE: $ 37 c <br />AMOUNT PAID <br />/ <br /> <br />DATE OF PA ENT <br /> <br />i \ '`,1 ' ' <br />PAYMENT TYPE <br />v, <br />- <br />RECEIPT 0 CHECK 0 <br />. _ <br />RECEIVEp,BY <br />--....r.:-----. <br />WORK PLAN PE