Laserfiche WebLink
San Join County Environmental Health D ment <br />DATE 11 2/16 / 2 012 MASTER FILE RECORD INFORMATION "MFR' <br />SNADED AREAS FOR Ellin USE ONLY <br />GREEN FORM <br />SITE MITIGATION & LOP <br />OWNER W. �pg I A. UNIT IV <br />OWNER FILE: COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION' CHECKIF OWNER CURRENTLY ON FILE WITH EHDN�< <br />PROPERTY OWNER NAME <br />BUSINESS/FACILITYISITE/PROJECT NAME <br />�-, Combined Support Maintenance <br />Shop (CSMS) RT CAL -A -II AIATIOVIV <br />SITE ADDRESS I PROJECT LOCATION 8020 Airport Way <br />IV 5y <br />CITY Stockton, CA 95206 <br />First <br />MI <br />Last <br />PHONE NUMBER <br />BUSINESS NAME <br />CA <br />Army National Guard <br />STATE ZIP <br />E-MAIL ADDRESS <br />Owner Home Address <br />COMMENT: <br />City <br />STATE <br />ZIP <br />Owner Mailing Address <br />10620 Mather Blvd. <br />Mailing Address City <br />Mather <br />State CA <br />Z]p 95655 <br />❑ CORPORATION ❑ INDIVIDUAL ❑ PARTNERSHIP ® GOVERNMENT AGENCY ❑ RESPONSIBLE PARTY ❑ OTHER <br />SITE MITIGATION k ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP _ WATER QUALITY _ HW PIPELINE INVESTIGATION _ LOP <br />FACILITY ID # INV# ACCOUNT ID BIRO # ASSIGNED EMPLOYEE LEAD AGENCY: EHD_RWQCB, X DTSC _ EPA <br />b011 y11 OD 221`1 V5*2,C1q91 �qq <br />FACILITY FILE: COMPLETE BUSINESS/SITE/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 5. <br />BUSINESS/FACILITYISITE/PROJECT NAME <br />�-, Combined Support Maintenance <br />Shop (CSMS) RT CAL -A -II AIATIOVIV <br />SITE ADDRESS I PROJECT LOCATION 8020 Airport Way <br />SUITE # BUSINESS PHONE t <br />CITY Stockton, CA 95206 <br />STATE ZIP <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 <br />KEY2 <br />Mailing Address WDIFFERENT from Facility Address <br />Attention: orCare Of (optional) <br />Mailing Address City <br />STATE ZIP <br />I!t <br />[ffl00 q <br />COMMENT: <br />THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Responsible Party identified above. <br />BUSINESS NAME Attention: orCare Of (optional) <br />Mailing Address PHONE <br />CITY STATE ZIP <br />' AccouNTADVRFec for fees and charges -,"IJ!ER FACILITY/BUSINESS THIRD PARTY BILLING <br />5m5zy <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: f, the undersigned Applicant, certify that I am the Owner, Operator, Authorized Agent, or Responsible Parry and I acknowledge that all PERM1TFEES, <br />PENALT/ES, 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 <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 environmental assessment information to SAN JOAQUIN COUNTYIRONMENTAL 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) `- SIGNATURE <br />L <br />TITLE TAX ID # <br />Approved By Date Accounting Office Processing Completed By Dete E L <br />SITE MITIGATI N AMOUNT PAID <br />DATE OF PAYMENT PAYMENT TYPE RECEIPT # <br />CHECK # RECEIVED BY <br />WORK PUN PE <br />FEE: $ <br />Z15? <br />