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01!0412011 10:11 530895816 h1R KOPV PAGE 02.''02 <br /> S;SJ�n County Environmental Health r,artment <br /> DATE= Jan 3, 2011MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION& LOP <br /> SHADED nREAg-EOREHO uBE ONIS OWNER ID* CASH A UNIT I V <br /> OWNER FILE:COMPLETE THEFOLLOW/NG PROPERTY OWNER INFORMA77 N. CHECK IF OWNER CURRENn Y ON 117L E W1 rH E H 0 <br /> PROPERTY OWNER NAME P n (530) 666-2185 <br /> First ARl Last PHONE NUMIMR <br /> BuslNess NAME FIRST STUOFNT BUS FACILITY E-WAIL ADDRESS <br /> Owner Home Add.eae 811 North Street <br /> City Woodland STATE CA zip 96895 <br /> Owner Mailing Address Some All Above <br /> Mailing Addmas City stars ZIP <br /> CORPORATION X❑ INDIVIDUAL❑ PARTNERSHIP© FEED Aarmcv❑ OTHER❑ <br /> Slim MITIGATION_ftMRONNENTAL AsSlSEmeNT�VOLUNTAIIY CLEANUP_WAYPR QUALITY� KW PIPCLINE INYEST eAT10N IAP <br /> FACILITY.10 A INV* ACCOUNT ID JPR#1 ROP ASSIONED E,MVLOYPE LEAD AOENQY:EH6_RV Oft -Me^EPA. <br /> FACILITY FILE COMPLEM7NEFOcL0§WVG BUSINESS I FACILITY!SITE/NFORMAwtv.- <br /> I6 this a New Business LOCATION net previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yrr Q NO X❑ <br /> Is this an Eximmo Business LOCATION but a NEw TYPE of regulated Bualness7 YEE5 0 No xl] <br /> SusiNEaSIFAcILrrylSiTENAME FIRSTStudent Bus Facility <br /> 917E ADDRESe 2005 NAW DRIVE SUITE S BUSINEaS PHONE 209.4864708 <br /> CITY STOCKTON STATE ZIP 96202 <br /> BOAROOrSUPERVISORDISTRICT LQCAVONCODE KEY1 KEY2 <br /> Mailing Address tfD/FFEREArrfivm FecatyAdldre" Attention:orCare Of(optional) <br /> Moiling Address City STATE Zip <br /> SIC Door # r CDNMEt1T <br /> THIRD PARTY BILLING INFO: Complete If Billing Party is different from Property Owner or Facility Operator identified above. <br /> Husimriss NAME KR ENVIERONMENTAL Attention;orCare Of (options/) <br /> Mailing Address 1026Almendla Court PHONE(530)521--26 <br /> 7 <br /> CRY CHICO STATE CA IIP 95926 <br /> BGLYIIIiYT_Ar1Jl1B£SS for fees and chargee OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> OtLLING AVD CQMTLt4NCE ACKCNOWLFACMRNT: 1,the undersigned Applicn-t,certify[lilt I nm the Ow/ter,Opereter,nr Authorked ngrnl of this business,and I ncknovrledge that All P9Rmff TEE4, <br /> ftut,1Tm4,ENnvcFwNTCIIAxin And/or 170mi.11CHAmmv gsrodated with thin opcmdon will he hiTlcd tome at the addrecc Identified nlwve as the I=r)NTAnnrrrST for this site- 1 ako certify that Rll <br /> infnrmytion provided An this application a true and correct; And that all regulatcal Activides will be performed in Acenrdnnec wlth all AplNicsble SAN JOA011IN COUNTY Ordinance Coda Rnd/or <br /> Standard,nod STATt and/or FEDERAL Laws oed Rt elation. As the undenignnl owner,operator,or xMt of the property located At the above Iltdfity/site addrrm,I hereby nuthorivc the release of <br /> any and All multi and envirnnmcntal asseelmmAL <br /> cnt information to SAN JOAQUIN('OUNTV ENVIRONMENTAL HEM EPARTfVKNTqv90 as it i14 Avnilnble and at the t,rtre time it is <br /> prvvldeo to me or my mpr"cnMtim <br /> APPLICANT NAME(PLEASE PRINT) MIKE GDODWfN SIGNATURE <br /> TITLE Sr.Gedoglet TAX ID <br /> Approved By Date Accounting ORice Processing Completed By Owls <br /> SITE MM0AT1ON A*wtj r PAID DATE OF PAYMENT PAYMENT TYP£ RECEIPT tt KS RECovzo BY ',Wtyltlt PutitpE <br /> Fee: <br /> I <br />