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San Wquin County Environmental'Health impartment DATEMASTER FILE RECORD INFORMATION"MFR" GREEN FORM 6/20/2012 SITE E MITIGATION&LOP SHADED AREAS FLEHD UEE Ot11A OWNER IDR -CASE111 ' 2371 UNIT IV OWNER FILE:COMPLETEMEFOLLOW/NG PROPERTY OWNER INFORMAnoN: CNEcxw OWNER CURRENrLroNFlLE.,HNTNEHD PROPERTY OWNER NAME Ismael Rivera - P09) -462-3374 First - MI Last PHONE NUMBER- $USINEss NAME y E-MAIL ADDRESS Rivera Upholstery Owner Home Address 1717 South Center Street City STATE ZIP Stockton CA 95206 Owner Mailing Address Same as above Mailing Address City State Zip CORPORATION❑ INDPODUAL®: PARTNERSHIP❑ FED AGENCY❑ OTHER❑ SIT$MrnaAT1oN_EuviRONR/ENTAL As:3ommENT_VowmrARY CLEANUP_WATER QUALITY »IIT PIPELINE INVEZaT14ATION LOP X 4 � fir+p as,r r�-v �r4,17 FACit rrrID* INVF AccauNTtD PR 11fRO f qq � + �<' a f.i�`3. :.r k j�f ' �2371 0110 4' � bi i - h `�'% FACIUW FILE. Cowm7F TwFoLww w BUSINESS/FACILITY I SITE INFoRm477m- I Is this a NEW Business LoCATioN not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT?, Yrs ❑ No 4 j Is this an EXISTINe Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No i - SUSINEssIFACiLITY/SITE NAME Same as above SITE AOOREss SURE it- BUSINESS PHONE CITY STATE Zip . BOARD OF SUPEItVIaOR Dlsrglrr LOCATIOIECODE KEY7 KEl2 Mailing Address iIDlFFEREMrn frcFRc!/ItyAddrlesa Attention:orCare Of( ) Mailing Address City STATE ZIP SIC cow' APN E CvMMEifr: 1" 5-072-28 7'IIIM PANTY BILLING INFO: Complete if Billing Party is different from Property Owner orFaclllty Operator identified above. BUSINESSNAME pSC Industrial Outsourcing, LP Attention:orcareOf (opdonaf)Paul Anderson Mailing Address 210 West Sand Bank Road PHONE I 618 281--1543 Crrr STATE _Zip Columbia IL 62236 AmauaAaQwIm for fees and charges OWNER FAciu Y/BuSINESS THIRO ARTY BILLING Brmimr.AND COM►uANcg At KNOWLEDCMEIYT: 1,the undersigned Applicant,certify that I am the Owner.Opeater,or Autharked Agent of this Business,"I acknowledge that all PERMIT FEss't PENALNES,ENFOAC.EMZNT CH4RCES and/er,HOURLYCHARGP.S associated with this operation wig be billed to me at the address ldentifltd above as the AccouNrAOnREss for this site-I also certify that all information provided on this application Is true and correct;and that all regulated activities will be performed In accordance with all applicable SAN JOAQUIN COUNTH Ordinance Codes and/or Standards and STArE and/or FEDERAL Lam and Regulations. As the undersigned owder,operator,or agent of the property located at the above facility/site address,1 hereby aWhorin the release of any and all resulb and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as as it is available and at the same time It Is provided tome or my representative. - APPLICANT NAME(PLEASE PRINT) Paul Anderson SIGNATURE 1 I TITLEProject Manager TAX ID# 27-3065989 ff ved By Date Aee�nting Olflos Processing Completed Bir Date MITIGATION AMDUN7 PAID DATE Or PAYMENT PAYMENTTYPE RECEIPT• CHECK* Rccewco BYKp$ - "-•I� k '