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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> O"'E If MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION& LOP <br /> BHGRED 6REAS FOR EB12 us,ORLY OWNERIDA CAeeA UNIT IV <br /> OWNER FILE.COMPLETE PROPERTY OWNER/REBPONSJULEPARTY INFORMATION: CHEOK//OWNER IECfflaumiLYONgfEWITHEHDEl <br /> PROPERTYOWNERNAME Maria & Christian Zamorano (2094703905 <br /> FIRST MI Lnsr PHONENumilm <br /> BUSINESS NAME E•W ILADURESS <br /> OWNEq HOMEADDREBS 2114 Aztec Avenue chis73ahoo.com <br /> 0" <br /> Stockton GACA T,P 95206 <br /> OWNER MAIUNO ADDRESS 2114 Aztec Avenue <br /> MAIuw ADDRFASCIN Stockton BTATe LP <br /> tqN CA 95206 <br /> 1:1 CORPORATION Id INDIVIDUAL 1:1 PARTNERSHIP ❑GOVERNMENTAGENOY ❑RESPONSIBLEPARIY <br /> [I OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP_ <br /> FAOILTTYIDA INVA ADooUNT ID PRAIF geaaaaa. <br /> (19 53bflEMPLoyee LeAOAoexoY:EHO_RWQCB DT80_EPA_ <br /> co IV `S <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPORTMENT? YES ❑ No LY <br /> IS THIS AN EIISTINO PROJECT LOCATION,BUT A NEWSOOPE OF WORK? YES No ❑ <br /> BUSN:ESSIFAOILl1YISITIIPROJEOT NAME Former Siebold Construction Co. <br /> SRe ADORESSIPRMOTLWAMN <br /> 820 S. American Street BURSA BUSINESS PHONE <br /> CITY <br /> Stockton STATE CA Zip 95206 <br /> BQMDQP BDPERWBDq DIBrngT LOOpTgN 000E Keyl KEY2 <br /> MI1tuN0 ADDRESS,IF DIFFERENT FROM FAOILITYADDRESB ATTENTION:OgOAgE OF(OVRONAef <br /> MAIUNOADDRESSORY <br /> STATE LP <br /> DE APNA COMMENT: <br /> !T;HIRDPARTYBILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME <br /> G H D Inc. ATreNTION;onoARe OF(ovTADNAe) <br /> MAIuxo ADDRESS 2235 Mercury Way, Suite 150 PHONE <br /> (707) 523-1010 <br /> Orly <br /> Santa Rosa STATE CA zP 95407 <br /> aaaaaaa <br /> ACCOUNT ADDRESS TO SEND FEESAND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLINOI$ <br /> JJIIA INC AND CO\PLIANCY A K'OR'I rOC IrNT: I,the mWenigned Appliennt.Certify fhnt I len the CAPOeq OpemlaA AlnharkedAgeol,or Ralunalble Parbi and I Achnouledge Ihal all PEROIr FLES, <br /> PEARLY/IS',EXfI1RCF1lEM1TCIIARG!_f nnd/Or I/lIIIW.YCl/ARrf..l'nS50dolol Mill,Thi I"J"I nill be billed 10 ma at ILC nddsns IdPndfiN Obol'P nr Ibe ACCOUATdODREC\'for Ib[f si1P. I Atso Certify/hot all <br /> In10,n n ion proAdol on ill[,nppirathni 6(rue and correct;and flint 01 rquIs d Actl\illes)1II be porfarnied In acco"InneP ullh all nphll<n ble S\R JOAQUIR COU,\T l'GRDIYA.\'CE CODES nIIJ/Or <br /> STANDARDS and STAR:and/or FEDERAL Inns 0-1 REGVl ATIDSB .b the undersigned Onner,OpernMr,An/Anrfeed,JRenl,or Rgiiun ddle Pnrly for file project located sbare under facililyAlte nddreu,I <br /> he,eby nudiori o file Blease or nal'and all resins,rtporb,and other en ironnsenlnl ossesunna infornni ion 10 SAN JOAQUIN COIP"rl'F1NV1 TOS.IEYTA I.TIG I.7I1 DEPART.IwNr at soon as it H nl'oilnblc <br /> and in the snmc dme It I\Pro\idpl to nit or my repr"critatMe. <br /> APPUOANT NAME(PLEASE PRINT) Ryan Crawford BgHATupE <br /> guo�— <br /> n"E Project Geologist rARIDA <br /> AFFADVED BY DATE p000UNTWQ GPFIOEPROO[eelxoCOM➢IETEp By DAte <br /> SITE INIMOATION AWUHTPAlo DATe OPPAYMENT PAYMENTTYPE RECEIPTA CHEONA REoeIVEO BY WORK PLAN PE <br /> Fee:a <br />