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San Join County Environmental Health DOrtment <br />DATE11 2/16/2012 --ll MASTER FILE RECORD INFORMATION "MFR' GREEN FORM <br />I I1 SITE MITIGATION & LOP <br />SHADED AREAS FOR EHO USE ONLYOWNER ID# ;?,o '57 CA:SL�i-y. <br />UNIT IV <br />� y �C[�//� \ s <br />OWNER FILE: CompLETF PROPERTY OWNER/ RFSPnNRIRI F PARTY Aixnpmdrin'La,•"I &HECK/F OWNER CURREHTLYON FILE WITH EHD fR] <br />PROPERTY OWNER NAME <br />INV# ACCOUNTID <br />EU/RO# ASSIGNED. EMPLOYEE <br />LEAD' AGENCY- EHD RWQCB,XDTSC_EPA <br />rA boy <br />/a//_ 1 5q - -;.66 <br />CCCNNNK� <br />V% T1 i lo9q <br />First <br />MI <br />last <br />Attention: orCare Of (optional) <br />PHONE NUMBER <br />BUSINESS NAME <br />CA <br />Army National <br />Guard <br />COMMENT: <br />E-MAIL ADDRESS <br />Owner Home Address <br />City <br />STATE <br />ZIP <br />Owner Mailing Address <br />10620 Mather <br />Blvd. <br />Mailing Address City <br />Mather <br />State <br />CA <br />zP <br />95655 <br />❑ CORPORATION <br />❑ INDIVIDUAL <br />❑ PARTNERSHIP ® GOVERNMENT AGENCY <br />❑ RESPONSIBLE PARTY ❑ OTHER <br />SITE MITIGATION f- ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP _ WATER QUALITY _ HW PIPELINE INVESTIGATION _ LOP <br />FACILITY ID# <br />!74l <br />INV# ACCOUNTID <br />EU/RO# ASSIGNED. EMPLOYEE <br />LEAD' AGENCY- EHD RWQCB,XDTSC_EPA <br />rA boy <br />oo z2r� <br />V% T1 i lo9q <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 <br />FAc1LI I Y FILE: COMPLETE t3U51Nt55I SI1 1:1 PROJECT INFORMATION. <br />Is this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No 7 <br />Is this an EXISTING Project LOCATION but a NEW SCOPE OF WORK? YES ❑ No 51 <br />BUSINESS/FACILITYISITE/PROJECTNAME Combined Support Maintenance <br />Shop (CSMS) AT CAL^,tveAty AI,4TI6)JjV <br />SITE ADDRESS I PROJECT LOCATION 8020 Airport Way <br />SUITE # BUSINESS PHONE <br />CITY Stockton, CA 95206 <br />STATE ZIP <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 <br />KEY2 <br />Mailing Address if DIFFERENT from Facility Address <br />Attention: orCare Of (optional) <br />Mailing Address City <br />STATE ZIP <br />SIC CODE <br />APN# � � � r / <br />COMMENT: <br />. nIKU 11-..R t . oaLLrriW IivrU; wrriptete if Dming rarCy Is airrerenr rram rroperty owner OrKesponsible Party identified above. <br />BUSINESS NAME Attention: orCare Of (optional) <br />Mailing Address PHONE <br />CITY - STATE ZIP <br />ACCOUNTADOREss for fees and charges VWNER FACILITY/BUSINESS THIRD PARTY BILLING <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1, the undersigned Applicant, certify that 1 am the Owner, Operator, Authorized Agent, or Responsible Party and 1 acknowledge that all PERMITFEEs, <br />PEN4LTIEs, ENFORCEMENT CHARGES and/or fIOURLYCHARGES 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 <br />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, Authorized Agent, or Responsible Party for the project located above under facility/site address, I <br />hereby authorize the release of any and all results, reports, and other emironmental assessment information to SAN JOAQU IN COUNTY IRONMENTAL HEALTH DEPARTMENT as soon as it <br />is available and at the same time it is provided to me or my representative. <br />i <br />APPLICANT NAME (PLEASE PRINT) <br />SIGNATURE <br />TITLE --� TAX ID f' <br />LLLLI <br />Approved By Date Accounting Office Processing Completed By Date <br />SITE MITIGATI N AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT # <br />CHECK # RECEIVED BY WORK PLAN PE <br />FEE: $ <br />�Xd/ -A <br />5mszy <br />