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SAN JSUIN COUNTY ENVIRONMENTAL HEALTH D�»RTMENT <br /> it GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION MFR SITE MITIGATION &LOP <br /> max.. ; i, ti OABEfI UNIT IV <br /> SX OEO AREASF ENDUSE ONLY <br /> ' ' �' 11 A CHECK/FONWER/SCURNENFLyoNFIGEHvTHEHD <br /> OWNER FILE:COMPLETE PROPERTY C NERI RESPONSIBLE PARTY INFORMATION: <br /> PROPERTY OWNER NAME George Betker 849-3272 <br /> (Z0� <br /> UMSER <br /> FIRST Ml I PMONEN <br /> EMAILAooREss <br /> BUSINESS NAME Geo Properties, Inc. <br /> OWNER HOME ADDRESS 2306 Jackie ourt <br /> STATE CA zIP 9 5 3 61 <br /> CITY Oakdale <br /> OWNER MAILING ADDRESS Same as above <br /> STATE ZIP <br /> MAILINNG.ADDRESS CITY <br /> EJ CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> WATER QUALITY_HMM PIPELINE INVESTIGATION_LOP <br /> SITE MITIGATION X ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_ <br /> SEA <br /> -- -- <br /> W;Miami <br /> FACILITY FILE:COMPLETE BUSINESS 11 HTEI PROJECT INFORMATION: <br /> ISTHISA NEW PROJECT LOCATION NOT PREVIOUSI.r REGULATED SYTHE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No [ <br /> YES No ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NE V SCOPE OF WORK? <br /> SUSINESsIFACILI Y1SITEIPROJECTNAME Forme JM Equipment <br /> SURER BUSINESSPHONE none <br /> SITE ADDRESS I PROJECT LOCATION 1245 W Charter Way <br /> CITY <br /> Stockton STATECA ZIP 95206 <br /> z AES <br /> ATDENTIONI ORCARE OF(OPTIONAL) <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS 2306 Jackie Court <br /> STATE CA ZIP 95361 <br /> MAILING ADDRESS CITY Oakdale <br /> 8�" tai r�J A€'` e -1„ y .s `�' 'i'�'`� .z... s .: r - INEi -r. i auk <br /> x' r <br /> st,11 212 <br /> THIRD PARTY BILLING INFO.COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER ORRESPONSIBLEPARTYIDENTIFIED ABOVE. <br /> Ar1ENTION:ORCARE OF(OPTIONAL) <br /> BUSINESS NAME <br /> PHONE <br /> MAILING ADDRESS <br /> STATE ZIP <br /> CITY <br /> FACILITYJBUSINESSE] THIRD PARTY BILLINGO <br /> ACCOUNT ADDRESS TO SEND FEESAND CHARGES: <br /> OWNERC y' <br /> BILLING AND t.Oh1PL1ANEE ACKNOWLEDGMENT: L the m ersigoed Applicant,certify that 1 am the Owner,Operator,Anihoria[Agen4 or Responsible Parry and f acknowledge that all FIRMLYF£ER, <br /> PENALTIES,ENFORCEMENT CHARGGiS and/or NOURLYCNARG associated with this project will be billed to me et the address ldenMiit above as thele SAN JTAnDR£ss for[hts site. 1 also COcerDES that all <br /> information provided on this application is hue and come t;and that all regulnted activities BID]be performed in accDrdancexRh to applicable SAN JOAQNN COUNTY ndG facRitANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL LRWs and REGUIX IONS. As the undersigned Owner,Operator,Authorized Agent,OF RespnsibE Parry far the Project located above order so.as <br /> address,e <br /> hereby authorize the release of any and aU results,reports,}ad other environmental assessment infOrTrailm to SAN JOAQUIN CGWI'Y EM'IRONN6NTAL HEALTH DE^PARTtigNT as soon as it is available <br /> and at the same time it is provided to me or my represeotadi c. <br /> a etker <br /> THEESIGNATURE/ `���(((///r Lryrr L <br /> APPLICANT NAME(PLEASE FBI Geor 9 ----�+— <br /> TAKIDs —1 -1 _ 3 as ) R,l <br /> ' Q <br /> ACGOUNNNG OFFICE PROCEHSING COMPLETED BY DATE _ <br /> APPROVED BY DATES S x§� ^/ I! ,QIECKji RECEIYE�Y q ' <br /> tSRE MRIOIITIDN AMouNTPAID <br /> FEE: <br /> N. <br /> ,e_ <br />