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SITE ADDRESS <br />3310 & 3330 East Main Street <br /> SUITEN BUSINESS PHONE <br />CITY Stockton STATE ZIP <br />CA 95205 <br />APNO _ h 7- tro-01 SIC CODE Comma: <br />Mailing Address ff DIFFERENT from Facility Address Attention: orCare Of (optional) <br />Mailing Address City <br /> STATE ZIP <br />Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES 0 No <br />Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES El No 0 <br />BUSINESS/FACIIJTY/SITE NAME Stockton Pharmacy <br />BOARD OF SUPERVISOR DISTRICT i LOCATION CODE / KEY1 K EY2 <br />1)6458q3 SIGNATURE <br />TAX # /680433534 <br />DATE August 15, 2012 <br />San Joaquin County Environmental Health Department <br />MASTER FILE RECORD INFORMATION "MFR" <br />OWNER ID# <br />CASE* SHADED AREAS FOR END USE ONLY <br />GREEN FORM <br />SITE MITIGATION & LOP <br />UNIT IV <br />OWNER FILE :COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION: CHECK IF OWNER amaein V ON FILE WITH END El <br />PROPERTY OWNER NAME 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 <br /> INDIVIDUAL 0 <br /> <br />PARTNERSHIP 0 <br /> <br />FED AGENCY 0 <br /> <br />OTHER 0 <br />SITE MMGATION ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP WATER QUAUTY HIN PIPEUNE INVESTIGATION <br /> <br />LOP <br />ASSIGNED EMPLOYEE LEAD AGENCY: EHD RVVQCB DTSC EPA <br /> <br />FACILITY FILE COMPLETE THE FOLLOWING BUSINESS / FACILITY! SITE INFORMATION: <br />THIRD PARTY BILLING INFO Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br />BUSINESS NAME Gribi Associates Attention: orCare Of (optiona0 <br />Jim Gribi <br />Mailing Address 1090 Adams Street, Suite K PHONE 707-748-7743 <br />Cm Benicia STATE CA ZIP 94510 <br />AmmutialfiDgiffis for fees and charges <br /> <br />OWNER FACILITY/BUSINESS <br /> <br />THIRD PARTY BILLING <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorised Agent of this Business, and I acknowledge that all PERMIT FEES, <br />PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNT ADDRESS 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 a hereby authorize the release of <br />any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D RTMENT as sy a it I avIIitble and at the same time it is <br />provided to me or my representative. <br />APPLICANT NAME (PLEASE PRINT) <br /> James E. Gribi <br />TITLE Sr. Geologist <br />Approved By Date Accounting (Mice Processing Completed By Data <br />SITE MITIGATION AMOUNT PAID DATE OF PAYMENT <br />FEE: $ <br />PAYMENT TYPE RECEIPT # CHECK S RECEIVED BY WORK PLAN PE