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SAN J0UIN COUNTY ENVIRONMENTAL HEALTH <br /> owARTMENT <br /> DATE MA,,(ER FILE RECORD INFORMATION %.. R" GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHD USE ON w OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IFOWNER/BCURRENTLYONF11EWfrH E H D ❑ <br /> PROPERTY OWNER NAME Edmond M Pimentel (209 610-1650 <br /> FIRST MI LAST PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> OWNER HOME ADDRESS 4202 Bass Road <br /> Cm Stockton STATE ZIP <br /> CA 95219 <br /> OWNER MAILING ADDRESS 4202 Bass Road <br /> MAILING ADDRESS CITY Stockton STATE CA ZIP95219 <br /> ❑CORPORATION ®INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT XX VOLUNTARY CLEANUP_WATER QUALITY HW PIPELINE INVESTIGATION LOP <br /> FACILITY ID# INv# AccouNr ID PR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD X RWQCB_DTSC_EPA_ <br /> -Y <br /> FACILITY <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ® No ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No ❑ <br /> BUSINESS/FACILITY/SITE/PROJECTNAME Acapulco Gardens Mexican Restaurant <br /> SITE ADDRESS/PROJECT LOCATION 1650 South EI Dorado Street SUITE# BUSINESS PHONE <br /> (209) 470-3132 <br /> CITY Stockton STATE CA zip 95206 <br /> BOARD OF SUPERVISOR DISTRICT V ( LOCATION CODE Q l KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> 3312 West Creek Drive Attention: Ernesto Renteria <br /> MAILING ADDRESS CITY Stockton STATE CA ZIP 95209 <br /> SIC CODE APN# ^ COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ATTENTION:ORCARE OF(OPT/ONAL) <br /> MAILING ADDRESS PHONE <br /> CITY STATE zip <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESSEY THIRD PARTY BILLING❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,fl tttltorizedAgettt,or Responsible Party and I acknowledge that all PERM17'FEE.S, <br /> PENALT/ES,ENFORCEMENT CHARGES and/or HOURI YCHARCES associated with this project will be billed to meat the address identified above as the AC'COUNTADORES:S for this site. 1 also eer6fy that all <br /> 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,AutborizedAgeat,or Responsible Party for the project locnted above under facility/Site address,1 <br /> hereby authorize the release of nny and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available <br /> and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) Ernesto Renterla ... ,� SIGN ATURE *, 91r. <br /> TITLE Business Owner/ Property Tenant TAXID# <br /> APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK## RECEIVED BY WORK P.LAANN PE� <br /> FEE:$ 3 <br /> 8- ( 7 — <br />