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SAN J*IN COUNTY ENVIRONMENTAL HEALTH pARTMENT <br /> DATE /U z`�-/'S MASTER FILE RECORD INFORMATION « R,� GREEN FORM <br /> Q SITE MITIGATION & LOP <br /> SHADED AREA9 FOR EHD USE ONLY („ / _ ���E'' '`�3�y UNIT <br /> I� I\ <br /> OWNER ID# 4V/II,N) JC�ASE# 'VV <br /> OWNER FILE-COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECKIFOWNERtBCURRENTLYONFTLEWTTH EHD Ej <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 /> CITY Stockton STATE zip 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# ACCOUNT ID PR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB-DTSC-EPA <br /> o q oP-o53 g d�N9,-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 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 (209) <br /> Stockton STATE CA7jp 95206 <br /> EOF SUPERVISOR DISTRICT C/ 11 .LOCATION CODE Q' KEY1 FKEY2 <br /> Ir <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OP770NAL) <br /> 3312 West Creek Drive Attention: Ernesto Renteria <br /> MAILING ADDRESS CITY Stockton STATE CA zIP 95209 <br /> SIC CODE APN# J��G � COMMENT: <br /> -t <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 EX THIRD PARTY BILLING❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,Authorized Agent,or Responsible Party and 1 acknowledge that all PERhHT FEES, <br /> PENALTIES,ENFORCEMENT'CHARGES and/o'HOURLY CHARGES associated\vith this project Will be billed to me at the address identified above as the ACCOUNTADDREv 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 al)I)licable 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 Par/) for the project located above under facility/site address,I <br /> hereby authorize the release of any and all results,reports,and other CDvironmental:)Ssessnlefit 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 Renteria SIGNATURE� ' <br /> TITLE Business Owner/ Property Tenant TAXID# <br /> APPROVED BY -'SATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE <br /> FFEE.$E MITIGATION OUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHE�CKp# RECEIVED BY WORKPLANPE <br /> 37q 3�5 <br />