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San Joaquin County Environmental Health Department <br /> DATEof/os/zols MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID#0W0O 2/75-'Ys CASE# ?/ 3 // UNIT IV <br /> OWNER FILE:CoMPLETEPROPERTY OWNER/RESPONSIBLE PARTY/NFoRMATION: CHECK-OWNER CURRENTL rON FILE WITH EHD <br /> PROPERTY OWNER NAME Farouk Dish ( 209\ 931-1044 <br /> First MI Lest `PHONE/NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> Rawlinson-Reade Property N/A <br /> Owner Home Address <br /> 10608 Oakwilde Avenue <br /> City Stockton STATE ZIP <br /> 95212 <br /> CA <br /> Owner Mailing Address same as above <br /> Melling Address City State 7Jp <br /> same as above CA 95212 <br /> ❑CORPORATION ©INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP WATER QUALITY HW PIPELINE INVESTIGATION LOP <br /> FACILITY ID# INV# ACCOUNT ID PR#1 RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD�RWQCB DTSC_EPA <br /> ��98a3 I�o�wNy <br /> FACILITY FILE: COMPLETE BUSINESS/SITE/PROJECT/NFORMAT/om <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 x❑ <br /> BUSINESSIFACILITYISITEIPROJECT NAME Rawlinson-Reade Property <br /> SITE ADDRESS I PROJECT LOCATION SUITE# BUSINESS PHONE <br /> 140 West Harding Way <br /> arty STATE ZIP <br /> Stockton CA 95204 <br /> BOARD OF SUPERVISOR DISTRICT ) LOCATION CODE / KEY I KEY2 <br /> Melling Address/fOIFFERENT from/Fac///tyAddress Attention:orCare Of(optional) <br /> 10608 Oakwilde Avenue <br /> Mailing Address City STATE ZIP <br /> Stockton CA 95212 <br /> SIC CODE APN# /37 O 2G-S 3 COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner ol-Responsible Party identified above. <br /> BUSINESS NAME Advanced GeoEnvironmental Inc. Attentlon:orCare of(optional) <br /> Robert Marty <br /> Melling Address PHONE <br /> 837 Shaw Road 209-467-1006 <br /> Crfy STATE ZIP <br /> Stockton CA 95215 <br /> 9GcouNTAIDDBEss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent,or Responsible Parry and I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGEs and/or HOURLYCHARGEs associated with this project will be billed to me at the address identified above as the ACCOUNT ADDRESS for this site. 1 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 aB applicable SAN JOAQUIN COUNTY Ordinance Codes andlor <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned(Nvner,Operator,Authorized Agent,or Responsible Party for the project located above under facility/site address,I <br /> hereby authorize tate release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY EWRONMENTA.L HEALTH DEPARTMENT as soon as it <br /> is available and at the same time it is provided to me or my representative <br /> APPLICANT NAME(PLEASE PRINT) Robert Marty SIGNATURE 7A7r—T <br /> # <br /> TITLE President TAX ID <br /> Approved By Date Accounting Office Processing Completed By Date �r <br /> SITE MITIGAAATIIIONffA!�O�T PAID DATE OF PAYMENT PAY,pMENT TYPEr RECEIPT# CHECK# RECEIVED BY W.O/`RtK PLAN PE <br /> FEE:$ R/ � �� ���� LL / "�/� -- / t n0 U (0U&Rgk ;mr <br />