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San j ,dquin County Environmental Health L.,;partment <br /> DATE of/o6/zols <br /> MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION &LOP <br /> SHADED AREAE FOR EHD USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:ComPLETEPROPERTY OWNER/RESPONSIBLE PARTY/NFoRw TioN: CHECKIF OWNER CURRENTLYON FILE WITH EHD <br /> PROPERTY OWNER NAMEParout: ciaP, \/ 2091 931-1044 <br /> First Ml Last PHONE/NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> Rawlinson-Reade Property N <br /> Owner Home Address <br /> 10608 Oakwilde Avenue <br /> olty Stockton STATE zip <br /> 9.,212 <br /> Owner Mailing Address same as above <br /> Mailing Address City same as above State Zip <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# IHV# ACCOUNT ID ]EPR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB_DTSC_EPA <br /> FACILITY FILE: COMPLETE BUSINESS/SITE/PROJECT/NFORwT/oN: <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/FACILITYISITEIPROJECT NAME Rawlinson-Reade Property <br /> SITE ADDRESS/PROJECT LOCATION SUITE# BUSINESS PHONE <br /> 140 West Harding Way <br /> CITY STATE ZIP <br /> Stockton -_ <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Melling Address/fDIFFERENTfrom FacilityAddress Attention:or Care Of(optional) <br /> 10608 Oakwilde Avenue <br /> Mailing Address City STATE ZIP <br /> stocktor. ''-1- <br /> SIC CODE <br /> ::2 <br /> PN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Responsible Party identified above. <br /> BUSINESS NAME Advanced GeoEnvironmental Inc. Attention:orCare Of (optional) <br /> Robert Marty <br /> Mailing Address PHONE <br /> 3� 3naw Road :'n J-467-1006 <br /> CITY STATE zip <br /> Stockton :'A 95215 <br /> Ac-co LNr TAfor fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the owner,Operator,Authorized Agent,or Responsible Pant and I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HDURLYCHARGES associated With this project will be billed to me at the address identified above as the ACCOUNT 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 FEuERAL Laws and Regulations. As the undersigned Owner,Operator,Authorized Agent,or Responsible Party for the project located above under facility/site address,I <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY E IRONME 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{# <br /> TITLE President TAX ID <br /> Approved By Date Accounting Office Processing Completed By Date <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE: <br />