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San Juin County Environmental Health Department <br /> DATE /0,22-1`2- MASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> SITE MITIGATION&LOP <br /> 6NAGLDI.9EASF0&EHD.UttDN" OWN"I0x CMlxSRv�G$Qlv2 UNIT IV <br /> OWNER FILE.COMPLiEw TNEFOLLOWINO PROPERTY OWNER INFOHMATfON: CNEGNe OWNER ouRREWrLroNni.EYrrN EHD <br /> PROPERTY OWNER NAME <br /> (209) 933-7045 X 2349 <br /> FNsf M/ Lee PHONENUMBEq <br /> BUSINESSNAME STOCKTON UNIFIED SCHOOL DISTRICT E-MNLADDREes <br /> Owner Home Address <br /> 701 N. MADISON ST. <br /> city <br /> STOCKTON BTAIE LP <br /> CA 95202 <br /> Owner Melling Address <br /> 1944 EL PINAL DRIVE <br /> Melling Acidness City <br /> STOCKTON state LP <br /> CA 95205 <br /> COPPoRATION❑ INONIOUAL❑ PARTNERSHIP❑ FEDAGENCY[3 OTHEHa <br /> $rrB Mm*ATION_ENUIROMMENTAL AasE"MENT_VOLUNTARY CLEANUP_WATER DUALITY_11W PIPELINE INVESTIGATION_LOP <br /> FACILITY 100 INvx AccauNrlD PRMROB ;/'' �It(fr 'RjQ�C� pryS,C E r <br /> FACILITITFRECOMFLErEnfEFocLolvrNOBUSINE35/FACILITY/SITE/NFoaMATyodv.• Y�S,' <br /> Is this a NEW Buelnese LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YEs ❑ N049 <br /> Is this an ExisnNO Business LOCATION but a New TYPE of regulated Business? Yes NO)m <br /> BUSINE3&tFACILrreI$n,ENAME AMOS ALONZO STAGG HIGH SCHOOL <br /> SITE ADDRESS <br /> 1621 BROOKSIDE ROAD BUDEx BUe MPHONE <br /> 209-933-7045 <br /> Cm <br /> STOCKTON STATE LP <br /> CA 95207 <br /> BDARO w SO pufMcy 2 LOCATH114 CODE / KEH Its <br /> Melling Address ifO/FFERENTAwn FaclllfyAtMreea Attention:orCare Of(opf/om j) <br /> Meiling Address City <br /> STATE LP <br /> SICCOOE APNB CaarlEefr: GG 1frG <br /> ezJ1 1 v GO EJhoV L � u � �EzCw'17F'' <br /> 7•IHRn PARTY MLLING INP07 Complete if BIIIIng Party is different from Property Owner orFeclllty Operator idei7tiTed above. <br /> BU31NEMNAME Cardno ATC Attention:o,Care Of(opxorW) <br /> Mailing Address 1117 Lone Palm Avenue, Ste. 201B PHONE <br /> (209)579-2221 <br /> Cm Modesto, CA 95351 STATE ZIP <br /> AGGGVtlLBOO8Es4 for fees and charges OWNER FACILfiY/BUSINESS THIRD PARTY BILLING <br /> >r unC OM • A 0 '• : 1,Me underalgssed Applicant ear*that Ism the Owner,aper ,or Authorized Agent of this BufircH,and 1 acknowledge that all PRMeT FRES, <br /> PINALTLFS,@ATOACINPNT(]URGES aMIM//OUALY L'N,.RGES afOClAhdµ11h ddr ppeTadnn w{D be dBHI hi 111e vt dM nddrH!NMNRtd abOV¢a IbeALCWATAUORRSf for INf f U.I OCTA,er,Hy that vll <br /> IMarmatlon provided an thb applkados Is true sed correct and that all RgldMed actividee wig be performed in ame4ana with W applicable SAN JOAQUIN COLWIY f oNlIname Codes and/or <br /> Ste"",and STATE and/or FEDERAL Lam and Regulatioae. As the undersigned ower,openlor,or Agent of the property located at the above faidllty/elle address,1 hereby suNloree Ile release of <br /> say and all results and en,imemental son5mwm information M SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a soon <br /> naami/t/1,San Mable And at the same time It is <br /> proddedtoN NAME(PLEAr my lafire. <br /> APPLICANT NAME(PLEABE PRINTI STEVE L. HREAKFIELD SIGNATIIq <br /> TITLE DIRECTOR, FACILITIES AND PLANNING - SUED TAXID0 <br /> Approved BY Dab AcaaunUnp Omce Procanlrp CHnplatad ny Dab <br /> SITS MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT hPE RECEIPTx CHECNx ROCEIVED BY 'WORN PUN PE� <br /> ��SU <br />