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I <br /> San Joaquin County Environmental Health Department <br /> DATE March 13, 2015 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION &LOP <br /> ShADEDARW FOR EHOUSE ONL OWNERID#OVODA-07 CASE# See-In,7f7ys UNIT IV <br /> OWNER FILE:CofPLErEPROPERTYOWNER/RESPONSIBLE PARTY/NFOR,MATION. CREORIEOWNER CURRERreyomnawwEH13 <br /> PROPERIYOWNERNAME Yan Shi (714)213-5698 <br /> Frst MI Last PHONENUMBER <br /> BUSINESS NAME E-IW L ADDRESS <br /> karenshi86@gmail.com <br /> Owner Home Addreas <br /> 8180 Commonwealth Avenue <br /> city <br /> Buena Park STATE zip <br /> 90621 <br /> Owner Malling Address <br /> 33 North Center Street <br /> Melling Address CityState <br /> Stockton CA P 95202 <br /> ❑CORPORATION (9 INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP_ <br /> FACILMtoN INV# Accou-10 PR#IRO# ASSIGNED EMPLOYEE LEADAGENCY:EHD'-RWQCB_DTSC_EPA_ <br /> 1�(J FAonz28 flPD04F1 JoNfiew <br /> FACILITYFILE: COMPLETE BUSINESS I SITE!PROJECT/NFORMA r/oN: <br /> Is this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES 0 No ❑ <br /> Is this an EXISTING Project LOCATION but NEW SCOPE OF WORK? YES ❑ No (] <br /> BUSINEmmiFACIDrY/STE/PRwecrNAME Howard Johnson Stockton Hotel <br /> SNEADDRESSIPROJECTLocarsiN SUITE# BUSINESSPHONE <br /> 33 North Center Street <br /> CITY STATE ZIP <br /> Stockton CA 95202 <br /> BOARD OF SUPERVISOR DISTRICT 0 / LDDAnaN CODE I eq KEY1 KEY2 <br /> MEIIIrig Address ND/FFERENTrrornFeel/ifyAddress AttenUon:orCare Of(opflomt) <br /> Mailing Address City STATE LP <br /> SICCODE ==I7, <br /> APN'-:S:):-n8>.4)7 COMMENr: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is dfffefent froln Property Owner or Responsible Party fdenr%fedabove. <br /> BUSINESS NAME Alpha Environmental Attention:orCare Of(opflonal/ <br /> Mailing Address PHONE <br /> 21818 Craggy View Street,#203 818-772-4483 <br /> Cm <br /> STATE <br /> Chatsworth CA 91311 <br /> AwarrNrAOORE.ca for fees and charges OWNER FACILITY/BUSINESS THIRDPARTYBILLING <br /> BILLING A\D COMPLIANCE ACKNOWLEDGaIENT: 1,the undersened Applicant,certify that 1 am the Ovnrry OPemMq.-Ivd�adxd d,^,enA or Rrspnosiblc ParOr and r ncknmdedge that all PERmTFEU, <br /> PE\:1LT/ES,EYTORCEVEtTC14IRGU andlor 1101 R Cloin; r associated nith this Project sill be billed to roe at the address Identified above m the AccocvTADDRm for this site. 1 also certify,that aU <br /> Information provided on this application is true and correct;and that all regulated actinides Bill be performed in nce.,danc,,,,ith all applicable SAN JOAQEIN COUNTY Ordinance Codes and/or <br /> Standards and 5T..ATE andfor FEDERAL Lons and Regulations. As the undersigned Tuner,Operator,Authorized Agent,or Responsible Party for the project located above under facility/site address,I <br /> hereby inthed.the release ormiy and all results,reports,and other environmental assessment infarmmion to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ns soon as it <br /> u available and at the same time It u provided to me or me representative. <br /> APPLICANT NAME(PLEASE PRINT) pND',REA C.HRISTIA,11 SIGNATURE <br /> TITLE 70TAX ID# - <br /> 171ELT E <br /> En1VIRONm6tdTAt EntC�INEU-ti � AI.P NA NVI(tilIJ MENITIiL <br /> Approved By ca AccounSrg Gilles Proceadno Compieled By Data <br /> SITEN1e7y—� — AMOUNT <br /> PPAID DAATEOFPAYMENf PAYNEHi TYPE RECEIPT# CHECK# RECEIVED BY WORK PUN PE <br /> 1'EE:S SyU J�f t7�t3af Ear 3�'� r'V g� <br />