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San Join County Environmental Health Df rtment f 6ef'N A- <br />GATE 2/16/2012 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br />SITE MITIGATION & LOP <br />SHADED AREAS FOR EMD USE ONLY OWNER ID* �D I, CASE Nt J UNIT IV \ ' <br />OWNER FILE TEPR�P <br />:COMPLEERTY 0WNFR/ RFRPnNRa <br />IRI F PARTY /AtcnMerrnAr•l CHECKrF OWNER CURRENTLYONFILEW/TN FI -In fRl <br />PROPERTY OWNER NAME <br />F <br />Shop (CSMS) AT' CAL^avejg1/ NATIb?1& <br />SITE ADDRESS / PROJECT LOCATION 8020 Airport Way <br />SUITE * BUSINESS PHONE <br />CITY Stockton, CA 95206 <br />/e//_ \/ 57q ,,, ;C�NI%O <br />\P/HOFNNENUMBERR <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 <br />First <br />KEY2 <br />MI <br />Last <br />Mailing Address City <br />STATE ZIP <br />BUSINESS NAME <br />CA <br />Army National <br />Guard <br />E-MAIL ADDRESS <br />Owner Home Address <br />City <br />STATE <br />LP <br />Owner Mailing Address <br />10620 Mather <br />Blvd. <br />Mailing Address City <br />Mather <br />state CA <br />7JP 95655 <br />❑ CORPORATION <br />❑ INDIVIDUAL <br />❑ PARTNERSHIP El GOVERNMENT AGENCY <br />❑ RESPONSIBLE PARTY ❑ OTHER <br />SITE MITIGATION 4- ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP _ WATER QUALITY _ HW PIPELINE INVESTIGATION LOP <br />FACILITY ID # INVN ACCOUNT ID/ RO $ ASSIGNED EMPLOYEE LEAD AGENCY: EHD_RWQCB�[ DTSC _EPA <br />bblf �I D Zzl� <br />F(:2;-',qq 1 b9q <br />FACILITY FILE: COMPLETE BUSINESS/ SITE/ PROJECT /NFDRMAT/nN_- <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 t. <br />BUSINESS/FACILITYISITE/PROJECTNAME Combined Support Maintenance <br />Shop (CSMS) AT' CAL^avejg1/ NATIb?1& <br />SITE ADDRESS / 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 ifD/FFERENT from FocilityAddress <br />Attention: orCare Of (optional) <br />Mailing Address City <br />STATE ZIP <br />�OD- <br />ff <br />,booq <br />COMMENT: <br />THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Responsible Party identibedabove. <br />BUSINESS NAME Attention: orCare Of (optional) <br />Mailing Address I PHONE <br />CITY STATE LP <br />AccouNrAaoREss for fees and charges UWNER FACILITY/BUSINESS THIRD PARTY BILLING <br />BILLING AND COhIPL1ANCF. ACKNOWLEDGMENT: 1, the undersigned Applicant, certify that 1 am the Owner, Operator, Autharized Agent, or Responsible Party and I acknowledge that all PERnnTFEES, <br />PENALTIES, E:VFORCEM1fENT 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 <br />information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQWN COUNTY Ordinance Codes and/or <br />Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned Owner, Operator, Authorized Agent, orResponsible Party for the project located above under facility/site address, 1 <br />hereby authorim the release of any and all results, reports, and other enAronmental assessment information to SAN JOAQU IN COUNTY IRONA1ENTAL HEALTH DEPART.MFNT as soon as it <br />is available and at the same time it is provided to me or my representative. <br />APPLICANT NAME (PLEASE PRINT) Zj `. SIGNATURE / <br />TITLE TAX ID # <br />Lc�lcl+J /�>sr/�/`�r�ib� �1 / 'LTt�� <br />Approved By Gab Accounting Office Processing Completed By Date v <br />SITE MITIGAT'pN AMOUNT PAID <br />DATE OF PAYMENT <br />PAYMENT TYPE RECEIPT * <br />CHECK N RECEIVED BY WORK PLAN PE <br />FEE: $ <br />,It <br />Z15? <br />6AA. il-A <br />5mw <br />