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San Joaquin County Environmental Health Department <br /> cc » GREEN FORM <br /> DATE 1/25/2011 MASTER FILE RECORD INFORMATION MFR SITE MITIGATION&LOP <br /> SHADEAS FOR EH <br /> ED ARO USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPETETHEFOLLOWINGPROPERTYOWNER INFORMATION.' CHECrc/FOWNERCURRENTLYONFlLEW7rNEHD <br /> L <br /> (209) 629-5070 (Ask for Sam Franco) <br /> PROPERTY OW NER NAME . <br /> First MI Last PHONE NUMBER <br /> E-MAILADDRESS <br /> BUSINESSNAME The Newark Group <br /> Owner Home Address <br /> STATE ZIP <br /> City <br /> Owner Mailing Address 2575 Grand Canal Blvd <br /> MaNingAddress City Stockton CA ZP 95207 <br /> CORPORATION® INDIVIDUAL❑ PARTNERSHIP FED AGENCY❑ OTHER El <br /> Sri E MmaxnON_ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLE/MUP_WATER QUAIIfY_HMV PIPELJNE INVEtTTifiATION-LOP <br /> — <br /> SITE <br /> INV# ACCOUNT ID PR#!RO# ABSIGNEDEMPLOYEE LEAD AGENCY:EHD_RWQCB, DTSC",_EPA <br /> irk!I lG !Ce <br /> FACILITY FILE COMPLETE THEFOLLowING BUSINESS/FACILITY/SITE INFORMATION: <br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an ExisMNG Business LOCATION but a New TYPE of regulated Business? YES El No <br /> BUSINEssIFACnJTYISrTE NAME <br /> $rTEADDRESS 800 West Church St SUITE# BUSINESS PHONE <br /> Cin' Stockton STATE ZIP <br /> I CA 95203 <br /> -—EH <br /> BOARD OF SUPERVISOR DISTRICT I LOCATION CODET�J�KE-Yl1 KEY2 . <br /> Mailing Address 1f0/FFERENT ham FacildyAddress Attention:orCare Of(oph4mal) <br /> STATE ZIP <br /> Mailing Address City FS <br /> CCODE APN# COMMENT: rl�lll4 l�j7lfC' I�RCIVT- r'+r� fl� <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESSNAME Attention:orCareOf(optlavrel) Richard Scanlan <br /> Dopaco, Inc <br /> Mailing Address 111E (484) 875-3760 <br /> 100 Arrandale Blvd <br /> ' STATE ZIP ' <br /> CRY Exton Email: Rick.Scanlan@Dopaco.com PA 19341 <br /> A[cat1RTAooaess for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am/he Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PEfuffrFFFs, j <br /> PF_TGLT/ES,ENFOxC0fEMf'CARGEs and/or HOURLYCHARGES associated with this operation will be billed to me at the address identified above as the ACCOUATAAARESS for this site. I also certify that <br /> all 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 endlor � <br /> Standards and STATE and/or FEDERAL.Laws and Regulations.As the undersigned owner,operator.or agent of the property located at the above facility/site add I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP RTMENT as soon as it s a ailable and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) Richard J. Scanlan SIGNATURE <br /> TAx Io -2106 8 <br /> TITLE Sr, VP Finance, Dopaco, Inc. <br /> Approved By Dote Accounting Office Processing Completed By DaW _ <br /> SITEMITIGATION AMoumT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PEeL <br /> _ <br /> FEE:$ I�7O <br />