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SAN J*IN COUNTY ENVIRONMENTAL HEALTH*ARTMENT <br /> DATE /v-ztl_r 3 MASTER FILE RECORD INFORMATION "MeR" GREEN FORM <br /> SITE MITIGATION & IOP <br /> sQ°°`°g szy <br /> SHADED AREAS FOR EHO USE ONLY OWNER ID# v Jo Cg3E# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECKIFOWHERISCURREHTLYONFILEWITH EHD <br /> PROPERTY OWNER NAME Edmond M Pimentel (20,9 610-1650 <br /> FIRST l✓Il LAST PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> OWNER HOME ADDRESS 4202 Bass Road <br /> CITY Stockton STATE zip <br /> CA 95219 <br /> OWNER MAILING ADDRESS 4202 Bass Road <br /> MAILING ADDRESS CITY Stockton STATE CA 7JP95219 <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# (Ny# ACCOUNT ID PR#1 RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD.X.RWQCB_DTSC_EPA <br /> d��wNy <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 /> Bus INESS/FACILITY/SITEIPROJECTNAME Acapulco Gardens Mexican Restaurant <br /> SITE ADDRESS/PROJECT LOCATION 1650 South EI Dorado Street SUITE# BUSINESS PHONE <br /> (209)470-3132 <br /> CITY STATE CA7fp 95206 <br /> BOARD OF SUPERVISOR DISTRICT V 11 LOCATION CODE 11 0/ KEY1 FKEY2 11 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:OR CARE 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(OPTIONAL) <br /> MAILING ADDRESS PHONE <br /> CITY STATE zip <br /> ACCOUNTADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITYIBUSINESSER THIRD PARTY BILLING❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent,or Responsible Party and 1 acknowledge that all PERmi7'FEEs, <br /> PENALTIES,ENFORCEMENTCHARCES andlo'HOUR/.YC/LARGES associated with this project will be billed to one at the address identified above as the ACCOUNTADDRESS for this site. I also certify that all <br /> inrormation provided on this application is true and correct;and that all regulated activities will be performed in accordance frith all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operator,Authorized Agent,or Responsible Part),for the project located above under facility/site address,I <br /> hereby authorize the release of any and all results,reports,and other environlnentel assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as itis available <br /> and at the same time itis provided to me or my representative, j <br /> t' <br /> APPLICANT NAME(PLEASE PRINT) Ernesto Rentella� SIGNATURE <br /> TITLE Business Owner/ Property Tenant TAXID# <br /> APPROVED BY / DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE <br /> SITE MITIGATION OUNT PAID DATE OF PAYMENTI PA/�Y[M�{ENNTf TYPE IIS RECEIPT�1 CHECK## RECEIVED BY WORK PLAN PE <br /> FEE: 375 �,� 1t�_�(_I`3 -- C �� I Cov"Vq <br />