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San Jc uin County Environmental Health` irtment <br /> DATE IL2119/2011ijMASTER FILE RECORD INFORMAION"iI :.. . GREENFORM <br /> SITE MITIGATION& LOP <br /> I UNIT 1V <br /> SHOOED AREAE FOR EHD USE ONLY OWNER ID# CASE# QO `(y o7 <br /> I. <br /> OWNER PILE:COMPLETETHEFOLLOWING PROPERTY OWNER INFORMATION•• ,f CHECKIF OWNER CURREAttxYONnLEtrrnf EHD <br /> ' <br /> PShwind { ` <br /> { <br /> PROPERTY OWNER NAME ucer Singh <br /> 209) 466-1734 <br /> I First Ml Last PHoNENumER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> Fast & Easy Mart N/A <br /> Owner Home Address !I <br /> 8807 Bargamo Circle j <br /> r <br /> city Ii STATE LP <br /> Stockton <br /> L CA 95212 <br /> Owner Melling Address same as above <br /> MWft Address City l " State Zfp <br /> I� <br /> { CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ �L ,FED AGENCY❑ OTHER❑ <br /> SITE MMOATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUA'LrFV 'h HW PIPELJNE INvarneAT1ON_LAP <br /> FAcIuTYID# INV# AccouNTID PR#�# <br /> ASSIGNEDEMPLOYEELEADAGENc-EHQ RWQOB^DT$C_EPA <br /> 3Tv6c� azq l�-s 9 <br /> FACILITYFILE CONPLEWTHEFOLLOWINGBUSINESS/FACILITY/SITE INF00MAnON' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? „ YEs ❑ No (] <br /> I Is this an D u TING Business LOCATION but a NEW TYPE of regulated Business? I YES ❑ No p <br /> 8U81NESSIFACILITYISrreNAME Past & Easy Mart <br /> $ITE ADORES9 <br /> 249 West Harding Way SurrE# BUSINESS PHONE <br /> I` � <br /> 7 <br />� <br /> CITY <br /> !3 STATE ZIP. Stockton iIy CA 95204 <br /> E�� <br /> --F- <br /> BDARDpFSUPERSORDIacr KEY1 KEY2 } <br /> I <br /> Malilrtg Address/fDIFFERENTrldotrlrFavllHyAddhim ( Atksnl don:vrCare Of(ophbrraQ <br /> I <br /> !Halling Address City STATE ZIP <br /> L�SffCCOOE APN# /37080 <br /> ?080 / COMMENT: i <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFBeillty Operator identified above. <br /> Bus ss NAME Advanced GnoHnvironmenta2, Inc. jl -Ro er arE—rem <br /> L y <br /> Mailing Address 6 . <br /> 837 Shaw Road PHONE <br /> 1r <br /> 209-467-1006 <br /> CITY STATE LP <br /> Stockton <br /> �, CA 95215 <br /> for fees and charges OWNER FACIUTYIBUSINESS .3 THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENAL77ES,EA'FORCEMENI'CHARGES and/or HOURLrCHARc;Fv associated with this operation will be billed tome at the address identified above as the ACCOUM'AODRECS 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 <br /> He ss <br /> with all applicable SAN JOAQUIN COUNT/'Ordinance Codes and/or <br /> Standards and SEATP and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located et the above facility/site address,l hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAMENT Hun as it is available and at the same time it is <br /> provided to me or my representative. Il <br /> APPLICANTNAME(PLEAsePRINT) Robert Marty { <br /> SIGNATURE <br /> ' A 7 <br /> TITLE President TAX ID# <br /> 0 <br /> Approved By Date Accounthii Office Prooeseing Completed B I! it ` Data - <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECKtI i RECEIVED BY WORK PLAN PE <br /> FEE: <br /> �_ <br />