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San Joaquin County Environmental Health Department <br /> DATE March 13, 2015 MASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> SITE MITIGATION &LOP <br /> SHADEDAREABUREHDU 0 DIyNER IDtl CABEtl UNIT IV <br /> OWNER FILE:COMPLETEPROPERTYOWNER/RESPONSIBLE PARTY/NFORMAT/ON: CNECKIFOWNER CuaaexrcrONpILEonfEHD � <br /> PROPERIYOWNERNAME Yan Shl 714)213-5698 <br /> Fist MI Lag PHONE NUMBER <br /> BUSINESS NAME Ei ILADDRESS <br /> karenshi86@gmaii.com <br /> Owner Home Address <br /> 8180 Commonwealth Avenue <br /> city STATE ZIP <br /> Buena Park CA 90621 <br /> Owner Melling Address <br /> 33 North Center Street <br /> Mailing Addreas City ZI state <br /> Stockton CA P 95202 <br /> :3 CORPORATION El INDIVIDUAL 0PARTNERSHIP OGOVERNMENTAGENCY ORESPONBIom PARTY El OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> FACILm IDN INVa Accoofn ID PR#IROtl ASSIDNED EMPLOYEE LEAD AGENCY:EHD_RWQCB_DTSC_EPA_ <br /> FACILITYFILE: COMPLETE BUSINESS/SITE/PROJECT/NFORMAT/OM <br /> Is this a NEW Project LOCATION not preVI0USly regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES El No 0 <br /> Is this an EXISTING Project LOCATION but NEW SCOPE OF WORK? YES 0 No O <br /> BUSINESNVACItTrYlSIrefft ear NAME Howard Johnson Stockton Hotel <br /> SIrEAODRESSIPROJECTLOCATION SURE# BUSINESS PHONE <br /> 33 North Center Street <br /> Cm <br /> STATE ZP <br /> Stockton <br /> CA 95202 <br /> BOARODPSUPERVISORDISTRIOT LOCATION CODE KEY1 KEY2 <br /> Melling Address HO/FFERENTfisaris Fae//lfyAddmia, Attention:orCare Or(optlorvlJ <br /> Mailing Address City STATE LP <br /> 91C CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete%(Billing Party is different from Property Owner or-Responelble Party identified above. <br /> BUSINESS NAME Alpha Environmental Attention:or Care Of(opNGrralJ <br /> Mailing Address PHONE <br /> 21818 Craggy View Street, #203 818-7724483 <br /> Cm <br /> STATE <br /> Chatsworth CA 91311 <br /> AccamizAaamw for fees and charges OWNER FACILITY/BUSINESSTHIRD PARTY BILLING <br /> BILLI9C.\,D Cnvrl.s.sseE A(RSOn'I.E.D6>IE]T: [,the uad,rs ened Applkant,,,riff,that 1 nm the Gann,Oprralnr,dmhoriwd,igenh or Respansible Porn'and 1 rick nonledge that all Pcxsnr FEa, <br /> Pcnirnrs,E..,FoRr[.uL%TCu ucGcf and/or flat RLSCaiwn associated with lbk project nill he billed tonic at headdress identified aho,e as the Amor:cTJnnRM for Ibis sill. I aka cmifi'lhm ail <br /> inforn ation prnided on th6 upplication Is true and corre l;and that all regulated aatkities will be performed In sceordame pith all applicable SAN JOAQI IS COUNTa'Ordinance Calei and/or <br /> Standards and STATE andbr FEDERAL Lans and Regulations. is the undersigned Gutter,Operator,Aulloid ed.Agent,or Respamible Pam,for the project located abase under facility/site address,I <br /> hereby nuthadra the release of am'and all results,reports,and other emirunmental assessment information to SAN JOAQL'IN COLN'fl'ENVIRON?IEN FAI.IIEALTII DEPAR CNIEN-r as soon as it <br /> is o,aRnble and at the same Bate it k prosided to me or mT represeomtim. r <br /> APPLICANT NAME(PLEASE PRINT) ANogFA l HRISTIAV SIGNATURE <br /> TITLE TAX ID# <br /> PRL7SECT ENVIRONm6Nt(pl ENCIINEk1L , ALPHA ENVIRuNI'nEUiItL <br /> Approved By Data AccounUN Offinsproaassatp CorpleteE By Dab <br /> SRELIRIOATION I AMCUNTPAID DATE Of PAYMENT PAYMENTTYPE RECEIPT# CNECK# RECEIVED BY WORX PIAK PE <br /> FEE:: <br />