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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAE FOR END USE ONLY OWNER ID# DABE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: GNeORIvOWWEA Is CmearxnywrxLewirm EHDEJ <br /> PROPEMOWNERNAME RGA Browne 800) 501-5589 <br /> FIRST MI LAST PRONENUMBFJI <br /> BUSINESS NAME WA.R.Z Stockton,LLC E ILAODREBS <br /> OWNERNOMEADDRESS <br /> Cm STATE LP <br /> OWNER MAIUNo ADDRESS 2402 S.California Street <br /> MAIUNOADDREBSOM Stockton STATE CA IJP 95206 <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY IN RESPONSIBLE PARTY El OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP_WATER QUALITY HW PIPELINE INVESTIGATION_LOP <br /> FACILITYID# INV# AccoUNTID PR#IRO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB_DTSC_EPA_ <br /> } -701Po� 2 <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS ANEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BYTHE ENVIRONMENTAL HEALTH DEPARTMENT? YES ® NO ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No ❑ <br /> BUSINESSIFACIUTYISMEIPROJEOTNA White AITDW <br /> SITE ADDRESS I PROJECT LOCATION SURE# BUSINESS PHONE <br /> 2402 S.California Street <br /> (800)501-5589 <br /> CITY Stockton STATE CA LP 95206 <br /> BOARD OF SUPERVISOR DISTRICT ' LOCATIORCODE J KEYI KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:OR CARE OF(OPPOWAL) <br /> MAIUNGADDRESSCITY STATE LP <br /> SICCODE APN# / G -) CJ7C7- 1 COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME Partner Engineering and Science,Inc. ATTENTION:ORCARE OF(0117001 Samantha Harris <br /> MAILINOADDRES9 PHONE 31O 615-4500 <br /> 2154 Torrance Boulevard,Suite 200 <br /> CITY STATE LP 90501 <br /> Torrance CA <br /> ACCOUNTADDREw To SEND FEWAND CHARGES: OWNERS FACILITY/EUSINESSI1 THIRD PARTY BILLING® <br /> 13ILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 Am the Oester,Operator,Amhoriecd Ageul,or Responsible Party ovd t erkaovd,dge that all PEAURTFra, <br /> PEvuT/Ef,E.v(OR(EVEYTCHsaeET nvd/or HorgLl'CNARees associated Pith this project Rin be baled to mat the address identified above ss the AorOtxrADDRect for thin rite. 1 also ee iry that aS <br /> fnfarinaNnv provided on this ap,Ur.d.D Is true and correct;and that all regulated nSfivides oil]be performed In accordance Pith ail applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or <br /> STANDARDS mad STATE and/or FEDERAL Laos and REGULATIONS.As the undersigned Gwuer.Operator,AuNlor1wdAgrNA or Respnl,SiNe P0}y for the project located above under facilitylsite address,I <br /> hereby authorize the release Of any and all multi,reports,and other environmental assessment Iuforn wdon to SAN JOAQUIN COUNTY ENITRONMLNTAI.HEALTH DEPARTMENT as soon as it IS available <br /> end at the Same ame it H provided 10 me or my repres Rmfi e. <br /> AnucANTNAME(PLE EPRINT) Samantha Harris SIONATIIRE <br /> TITLE Senior Project Manager TAX no 20-8264379 <br /> ffFEE: <br /> D BY DATE ACCOUMNOOFRGEPROCF NOCOMPLEIEOBY DATE <br /> "TSIOO'N'' ARGUNT PAID DATE Of PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORB.puH�E <br /> 9Il '3�� H-7-I I 0r+�K rz�b� „,*e a`7105" <br />