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EnvironmentalHealth
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2900 - Site Mitigation Program
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PR0522496
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Last modified
2/15/2019 5:20:34 PM
Creation date
2/15/2019 2:42:16 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
FIELD DOCUMENTS
RECORD_ID
PR0522496
PE
2957
FACILITY_ID
FA0015317
FACILITY_NAME
FLAG CITY CHEVRON
STREET_NUMBER
6421
STREET_NAME
CAPITOL
STREET_TYPE
AVE
City
LODI
Zip
95245
APN
05532024
CURRENT_STATUS
02
SITE_LOCATION
6421 CAPITOL AVE
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
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EHD - Public
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CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT <br /> State of California. <br /> ss. <br /> r' County o <br /> I ' <br /> On before me, �J <br /> at N and Title O ce (e. ,"Jane Doe,No Public") <br /> personally appeared <br /> e(s) gn <br /> t <br /> ❑ personally known to me <br /> }]fir ved to me on the basis of satisfactory <br /> ( ce <br /> to be the person( ?se. names/� <br /> CJ�SI�E ytO subscribed to th within nstru ent and <br /> - nbt�P�c #i ORF acknowledged t e that he/she/th d <br /> Sonire_ <br /> �� Ccf;��Q � the me n his/herMeir authorized ,I <br /> y capacity(I and that by r <br /> res V signatu n the instrument the person , or <br /> the entit upon behalf of which the son(s) <br /> acted, xecuted the instrument. <br /> WITNES y hand and official seal. <br /> I, <br /> I' Place Notary Seal Above Sig oW P k <br /> OP ONAL <br /> Though the information below i required by law,it may prove valuable to persons relying on the document <br /> is and could prevent du/ent removal and reattachment of this form to another document. <br /> I <br /> Description of Attached Document <br /> Title or Type of Document: <br /> Document Date: j Number of Pages: <br /> Signer(s) Other Tha Named Above: I <br /> I I <br /> Capacity(ies) Claimed by Signer <br /> Signer's Name: _ <br /> I' l❑ Individual <br /> I, Top of thumb here <br /> ❑ Corporate Officer—Title(s): <br /> ❑ Partner—❑ Limited ❑ General <br /> ❑ Attorney in Fact <br /> ❑ Trustee <br /> ❑ Guardian or Conservator <br /> I I <br /> ❑ Other: <br /> Signer Is Representing: <br /> ( I <br /> I, <br /> 01999 National Notary A iation•93so De Soto Ave..PO.Boa 2402•Cl eswoM,CA 91313-2002-w rallonalnolary.org Pm No.590 Recider'.Call Toll-Free 1600-8766821 <br />
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