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SAN JOIN COUNTY ENVIROt MENTAL HEALTH DEOTMENT <br /> .% ff GREEN FORM <br /> DATE MASTER FILE RECOIL INFORMATION MFR SITE MITIGATION &LOP <br /> y�Aum.`cozEHOU EDNLY <br /> s�71412 UNIT IV <br /> OWNERID% <br /> DIA)a0Zo�43 RASE# <br /> CNECKff OWNER l9 CUWNENRYON fiLEWITX END <br /> OWNER FILE-.COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY NFORMATION: 20 570.1815 <br /> PROPERTY OWNER NAME Kenneth Tate ( 9t <br /> Fn Sr <br /> MI LAST PHONE NUMBER <br /> EMAIL ADDREx <br /> BUSINESS NAME Tina's Investing, Inc. openairmall@hotmail.com <br /> OWNERHOMEAODRESS 2715 West Kettleman Lane, Suite 203 17 <br /> STATE CA zM 95242 <br /> CITY Lodi <br /> OWNER MMDNG ADDRESS 2715 West Kettleman Lane, Suite 20 -317 <br /> STATE CA ZIP 95242 <br /> MMUNO ADDxesacm Lodi <br /> ❑CORPORATION []INDIVIDUAL ❑PARTNERSHIP ❑C OVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT=se— <br /> (AD <br /> VOLUNTARY CLEAN P_WATER QUALITY_MW PIPELINE INVESTIGATION_LOP <br /> FACILT'ID% INV# AccoUNTIOA SIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB_DTSc_EPA0229o1 ARDOq'i �►•"`""� <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION' <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENWRONM TAI.HEALTH DEPARTMENfT YEES O No 0N <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? <br /> BUSMESSIF=UTY,ISDEWROJEOTNAME Tina's Investing, InC. <br /> SurtEa BUSINESS PNoae <br /> SREADDRESSIPROJECTLOCATION 1947 East Channel Street <br /> sr"'E CA'P 95205 <br /> CITY Stockton <br /> BOARD OF SUPERVISOR DISTRICT .✓l) <br /> LOCATION CODE of KEYT KEY2 <br /> VV ATTENTION:ORCARE OF(OPTIONAL) <br /> MAILING ADDRESS,IF DIPFEBENT FROM FACILT'ADDRESS <br /> STATE 7JP <br /> MAILING AGGRESS CITY <br /> PARTY <br /> SIC CODE APN# I -Irl„��'7 COMME T: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IIS•DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE 1 <br /> SPONSE OF/OPT/A)ENTIFIED ABOVE. <br /> BUSINESS NAME <br /> PHONE <br /> MAILING ADDRESS <br /> STATE LP <br /> CITY <br /> OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING❑ <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: and 1 aclmowledge that an PERMTi PfJa, <br /> R ND CoMPLw+EE ACEN wLSDC ENT: L Me undersigned Applicant,Unify that 1 am a 0,,s ,Operamr,AalAorL sf Agen4 or Responslefe Pnrty <br /> PILL" SSY,o OftCESTSATGUeGES and/or XDTIIU.YCLARz%Ey associated with this project will be b'Ted to me at the address ideolified above.the A"WAWRW for this site. I dao Con Mat all <br /> iMormafion Provided an this apptimtiav is nwe end mrre,and that all regulated activities wit be AWmrlud A perforeaui I.acM oreaResponsi6la nParty To typilemrMe P j�Iomted above under facility site address,l <br /> STANDARDS and STATE and/or FEDERAL.Laws-Rd REGULATIONS. Aa Me andersig ed Olmer,OP rat. Jk <br /> F7P�Yr.Tr,DePnRia18NT as satin as it's""'able <br /> hereby authorize the rdense of any and an resdn,reports'and other a <br /> mvhrromevlal assemmt i srmadau to RAN JOAQ(IRI COUNTY ENV/ M1MRNTAL <br /> and at Meaame tion,His provided To me or my teprese leative <br /> APPLICANTNAMEIPLEASEPR111Tj Kenneth Tate/Tina's Investing, nc. <br /> SIGNATURE <br /> TABID# <br /> TILE `"'� <br /> APPROVED BY DATE 11CCOUMIfr00 PPOCEaawnI.WFLErm SY <br /> DATE 3 =- <br /> p/h ZQ GATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK RECEIVED BY WQI! C� E <br /> SIZE MDIr31?C J /UID J/22 //`v1 aJflY-1/ <br />