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San Joaquin County Environmental Health tepartment <br /> DATE 1 <br /> 07/01/2014 MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> SITE MITIGATION& LOP <br /> SHADED AREAS FOR END USE O ONLY OWNER ID# CASE# UNIT IV <br /> OWNER PILE:COMPLETE TNEFOLLOW/NG PROPERTY OWNER/NFORMAT/ON. OHECK,p OWNER CURRENTLVONFILEwirx EHDL1 <br /> PROPERTYOwNERNAme Mayra Cuevas /2091181- <br /> ` / 9950 <br /> First MI LOST PHONE NUMBER <br /> SUSINESSNAME EMAILADDRESS <br /> Cuevas PIoperty N/A <br /> Owner Home Addresses <br /> 504 East Charter Way <br /> City Stockton STATE LP <br /> CA 95206 <br /> Owner Melling Address <br /> same as above <br /> Meiling Address City State Ldp <br /> CORPORATION El INDIVIDUAL El PARTNERSHIP❑ FED AGENCY[I OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP—WATER QUALITY_IIW PIPELINE INVESTIGATION_LOP_ <br /> FACILITY IDK INV# AccouNTID PR#!RO# ASSIGNED EMPLOYEE LEac,AGENCY:EHD RWQCB_OTSC_EPA_ <br /> PACILITYPILEC0VPLETETNEFOLLOW/NGBUSINESS/FACILITY/SITE/NFORMATTON.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES © No ❑ <br /> Is this an EKISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESWACILDYISITE NAME Cua. Property <br /> SITEADDRESS SUITE# BUSINESSPHONE <br /> 1400-1410 California Street 6 518 east Charter Way <br /> Crtv Stockton STATE zip <br /> CA 95206 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE / KEY1 REYL <br /> Melling Addreas XD/FFERENrrromFRv1WAddrnss Attention:orCare Of(opNona/t <br /> Malling Addreas City STATE LP <br /> SICCODE APN# l/lo`I' <br /> O -3,L COMMENT: <br /> THIRD PARTY BILLING INP*: Complete if Billing Party is different from Property Owner orFacillty Operator ident ed above. <br /> BUSINESS NAME Advanced GeoEnvironmental or Attention:wCere Of(opblosa/t <br /> Daniel Villanueva <br /> MallingAddrees <br /> PHONE <br /> 837 Shdv Rased <br /> CRY <br /> SSTALE 955P <br /> tockton <br /> CA 95215 <br /> ACCOr forfees and charges OWNER FACILIT1BUSINESS HIRDPARTY BIWN <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that l am the Owner,Operator,orAuthorized Agent of this Business,and l aclim—owTedge that all P£RM?FEES, <br /> PENALTIES,ENMRC£MEMiCMRGES end/OrAOURLYCHARGEs associated with this operation will be billed tome at the address identified above as the ALTYIUNTADOR£KS for this site. I also certify that <br /> all information provided an this application is true and correct;and that all regulated acfivides will be performed in accordance with all applicable SAN JOAQUm 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 looted at the above facility/sin address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUI N COUNTY ENVIRONMENTAL HEALTH DEPAR tAENT As soon as it is available and at the Same fime it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) Daniel Villanueva SIGNATURE " <br /> TITLE Project Geologist TAX IDIIIR N/A <br /> Approved BY Date AccourrUnB OMCs PracavinO CanPletetl BY Dab <br /> S ITE MITIGATION AM PAID DATE OF PAYMENT P`AYMEN�TTTTPE RECEIPT# CHECK# RECEIVED BY WORK PLAN <br /> N PE <br /> FEES 7S5 (-J"i �I U�GLV tZT�i JO <br /> oYGY d C t-3o3 9 <br />