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San J'Squin County Environmental Health 4artment <br /> DATEMASTER FIE�= LE RECORD INFORMATION "MFR" GREENFORM <br /> 1� <br /> - SITE MITIGATION& LOP <br /> SHAVEDAREASFOREXDUSEONLY OWNER ID* 0000/r/,ev / CASE* UNIT IV <br /> OWNER FILE(COMPLETE THEFOLLOW/NG PROPERTY OWNER/NFORMAT/ON: CHEcir(F OWNER CumrExrzroxF2exrn(EHD� <br /> PRopsare OzaaeRNAME Mayra Cuevas 1209 I\ q.,9950 <br /> Find MI Last PHONE NUMBER <br /> BUSINESS NAME E-MAILAODRESS <br /> Cuevas Property N/A <br /> Owner Home Address <br /> 504 East Charter Way <br /> City Stockton STATE zip <br /> CA 95206 <br /> Owner Melling Address <br /> same as above <br /> Melling Address City state LP <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ FEn AGENCY❑ OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> FACILITYID* INV* AcCOUNTIO PRNIRO* ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWOCB_DTSC_EPA_ <br /> �Av �ZLIZb �Kob / 4� �Ftv X39 Z3 <br /> FACILITYFILE COMPLETE 7HEFOLLoww BUSINESS/FACILITY/SITE/NFORMA7mw <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES © No ❑ <br /> IS this an EKIs-nNG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESSIFACILITYISITE NAME Cuevas Property <br /> SITEAODRESS SUITE* BUSINESS PHONE <br /> 1400-1410 California Street & 514 East Charter Way <br /> Cm <br /> Stockton STATE <br /> CA 95 95206 <br /> BOARD OF SUPERVISOR DISTRICT r LOCATION CODE I KEY1 KEYP <br /> Meiling Address MOIFFEREWrtrusts FsclfifyAdc',aaa Attention:orCare Of(opeonal/ <br /> Melling Address City STATE zip <br /> SIC CODE APNN 'GT\r'O .3Z tiDMMENT: <br /> THIRD PARTY BILLING INFO: Complete/if Billing Party is different from Property Owner OrFaCility Operator identlffedabove. <br /> BUSINESSNAME Advanced Geoenvironmental Inc Attention:orCare Of(opyoTrW) <br /> Daniel Villanueva <br /> Melling Address PHONE <br /> 937 Shaw Road <br /> Cm <br /> zip <br /> Stockton STATE 9521 95215 <br /> ACCOURA'AOAWESS for fees and charges OWNER FACILITY/BUSINESS HIRD PARTY BILLIN <br /> BILLING AND COMPLIANCE ACKNOWLEm aup NT: 1,the undersigned Applicant,panty that I am the Owrter,Operator,or Authorized Agent Of this Business,and I acWiUwTaTgY that all PE2wT FEES, <br /> PENALTIES,ENFORCEMEVT CHARGES and/or Hll(/FLYCHARGES associated with this Operation WIII be bJIPd tome at the address identified above as the AcrouNTADORFSS for this site I also certify that <br /> 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 COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations As the undersigned owner,operator,or agent of the property located at the above facility/site address.I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR 1BNT as soon as it is available and at the same time it is <br /> provided to me or my representative <br /> APPLICANT NAME(PLEABE PRINT) Daniel Villanueva SIGNATURE <br /> TITLE Project Geoloyisc TAX ID# N/A <br /> Approved By Date pccaurUmg Oft.Processing Completed BY Dela <br /> SITE MITIGATION AM PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT* CHECK* RECEIVED BY WORK PEAR PE <br /> FEE:S 375 J 7—l—l� t� e.r `tel � 50 <br /> ��I l G -3CD <br />