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SAN JOA UIN COUNTY ENVIRONMENTAL HEALTHORPARTMENT <br /> DATE MER FILE RECORD INFORMATION GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IsCURRENTLYONFILE WITH EH <br /> PROPERTY OWNER NAME Edmond M Pimentel (209 610-1650 <br /> FIRST MI LAST PHONE NUMBER <br /> E-MAIL ADDRESS <br /> BUSINESS NAME <br /> OWNER HOMEADDRESS 4202 Bass Road <br /> CITY Stockton STATE CA zip <br /> p95219 <br /> OWNER MAILING ADDRESS 4202 Bass Road <br /> MAILING ADDRESS CITY Stockton STATE CA zIP 95219 <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# ACCOUNT ID PR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB_DTSC_EPA <br /> QL'ww-y <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 ANEW SCOPE OF WORK? YES ❑ No ❑ <br /> BUSINESS/FACILITYISITE/PROJECTNAME Acapulco Gardens Mexican Restaurant <br /> SITE ADDRESS/PROJECT LOCATIONSUITE# BUSINESS PHONE <br /> 1650 South EI Dorado Street <br /> (209) 470-3132 <br /> CITY Stockton STATE CA zip 95206 <br /> BOARD OF SUPERVISOR DISTRICT ✓ FLOCATIONCOIE FEY1 KEY2 <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# _ 3 COMMENT: <br /> 6 <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 /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER[] FACILITY/BUSINESS®( THIRD PARTY BILLING❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the(honer,Operator,Anthorized Agent,or Responsible Party,and 1 acknowledge that all PFRmuTFEFS, <br /> PENAL7'mv,ENFORC'EMFN%'CHARGES and/or f/0U1?LYC11ARCEs associated with this project will be billed to me at the address identified above as the ACcouN7'ADDREss for this site. I also certify 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,AuthorizedAgenl,or Responsible Party for the project located above under facility/site address, <br /> hereby authorize the release of any 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 /> t <br /> APPLICANT NAME(PLEASE PRINT) Ernesto Renteria SIGNATURE _ , ��, <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 PA/�YMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE:$ 375 3 7� /�—�l_1 L t � �OG tVT2 ' )1 I <br />