Laserfiche WebLink
SAN JOAARIN COUNTY ENVIROF MENTAL HEALTH DESTMENT <br /> DATE MASTER FILE RECOR INFORMATION"MFR" SITE MITIGATION&LOP <br /> e,. MF=== <br /> CASE. UNIT IV <br /> OWNER FILE COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY NFORMAION: <br /> CHECK if OWNER 18('itfRRENILYON FlLEHTrH EMD <br /> PROPERTY OWNER wAeR Kenneth <br /> Tate 209)570-1815 <br /> FIRST MI usr PHONE Nuownet <br /> EM LADORM <br /> BUNNEas NAME Tina's Investing, Inc. openairmall@hotmail.com <br /> OWNER HOME ADDRESS 2715 West Kettlernan Lane, Suite 2034 17 <br /> Om Lodi <br /> STATE CA "P 95242 <br /> OWNER MNLIHDAOMESS 2715 West Kettleman Lane, Suite 20 -317 <br /> MNurfDADDRESS CmT <br /> Lodi sT"TE CA �" 95242 <br /> ❑ <br /> CORPORATION ❑INOPADGAL ❑PARTNERSMP ❑ <br /> NMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SRE MITIGATION_ENVIRONMENTAL ASSESSMENT—VOLUNTARY CLEAN IV_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP_ <br /> FACILITY 1011 INYR ACDOUNTIO PRMIROIf A SIGNED EMPLOYEE <br /> LEAD AGENCY:EHO_RINOCB�DTSC.�EPA_ <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMAL N: pp�T <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRON TAL HEALTH DEPARTMENT? YES pt No <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? <br /> YES ❑ No PI <br /> SUBINEDBIFACIUT„jSRFJPRGIECT NAME Tina's Investing, Inc. <br /> SUITES BUSINESS PHONE <br /> SITE ADDRESS I PRDIECT LOCATION 1947 East Channel Street er <br /> STATE CAap 95205 <br /> CITY Stockton <br /> BOARD OF SDPERVIBOR DISTRICT <br /> 0' LOCATION CODE O / KEY1 KEYZ <br /> ATTENTION:ORCARE OF(OPrt0”) <br /> MAILING ADORESS.IF AFFERENT FROM FAaurr <br /> CORE" <br /> STATE LP <br /> MuuW ADDRESS CM <br /> SIG CooE APNfI <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT ROM PROPERTY OWNER oRR RRElpo <br /> CNMSIEBOLF PA�RT�IjENTIFIED ABOVE. <br /> Sum"E88 NAME <br /> PItL1HE <br /> MmunG ADDRESS <br /> STATE LP <br /> Cm <br /> ADCDUIaT ADONESB TO BEND GES <br /> FEES AND CHAR : OWNER❑ <br /> FACALITYIBUSINESS❑ THIRD PARTY BILLING❑ <br /> m no COMIa, xcE ACRNOWLEDGWN?: L the andermsiped Applicant,certify that I am a Owner,OPeramr,AuthorlyedAgen4 or RespanOlePa'V and 1 ulmowledge that Sf psaRTFM, <br /> PEfULTTPS,ENFOXCEMENTQ)nRGES and/or HotmtTCtsfacEv associate)with mK projeet will be b'IeJ a me at the adJress idmtiRed above ss the ACCOUIYI'ADOREa4 for this site. 1 also certify that of <br /> Information provided on this application is true and rorreet;and that of regulated activities hail be performed A ace;0,RESnce whdr of Pony <br /> forth SAN jest locceIrvtdoabo"nde fadlity/she address,I <br /> STANDARDS and STATE and/or FEDERAL,taws and REGULATIONS. As the undersigned Owner.O ar,ANRIorludAgea4 or Responsible Party far Bm project <br /> hereby authorize the release of auy and of rendu,report,and other em iremosental asxsammt i oMotion to SAN JOAQOIN COVNfY EN NMEN'1'AL DEPARTAff.NT as soon as it is available <br /> and at the same time it is provided to me or my represmdative <br /> APPUCANTNAME(PLEASEPMNT) Kenneth Tate/Tina's Investing, Inc. SIOtUTU0.E (11�I�/Xt Q, <br /> TITLE �'-�t Taut 1D/ ��— LL -rV I/3Oq <br /> APPROVED BY DATE <br /> L/ "mme OHOOfF PRonElSltro METED BY 11 DATE <br /> BITE MmOATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPTS CHECKY RECEIVED BY WgaAVJ1�PE <br /> FEE:f '7J�1`//1 <br />