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San J.--nquin County Environmental Health L ,jartment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION &LOP <br /> SHADED A_RAWQgEHQ_tll}E ONLY OWNER IDN CASE# UNIT IV <br /> OwMERFILE:COMPLETE THE FOLLOW/NGPROPERTYOWNER INFORMATION: CHEcxn, OWNER CURRENTLYONFILE WIrHEHD <br /> PROPERTY OWNER NAME <br /> First MI Last PHONE NUMBER <br /> BUSINESS NAME Knife River Corporation E-MAIL ADDRESS <br /> OWner Home Address PO Box 6099 <br /> city Stockton STATE Ca zip 95206 <br /> Owner Mailing Address PO Box 6099 <br /> Mailing Address city Stockton state Ca <br /> zip 95206 <br /> CORPORATION INONIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE Mm"TiloN ENVIRONMENTAL AsEEEEMENT_VOLUNTARY CLEANUP WATER QUALITY_ HW PIPELINE INVEsTIGAT1oN _LOP <br /> FACILITY <br /> IDS INV# AccouNT ID PR N/RO N <br /> F�. yyR <br /> FACILITY FILE COMPLETE THEFOLLOw/No BUSINESS I FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTiNENT? YES ❑ No IK1 <br /> Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES Qg NO ❑ <br /> BUSINESs/FACILrrYISfTENAME Knife River Corporation <br /> SITE ADDRESS 639 West Clay Steet SUITE# Bust r�s�y} -15302 <br /> CITY Stockton STATE Ca" 95206 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE Keyl KEY2 <br /> Mailing Address ifD/FFERENTfrom Fac/// Address Attention:orCare Of(options!) <br /> PO Box 609 <br /> Mailing Address City Stockton STATE Ca ZIP 95205 <br /> 11 SIC CODE APN N COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Advanced GeoE nviron mental, Inc. Attention:or-Care Of (optional) <br /> Mailing Address 837 Shaw Road PHONE 209 467 10006 <br /> CITY Stockton STATE Ca vP 95215 <br /> Accat 290ggESS for fees and charges OWNER FACILITY(BUSiNESS XHIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERWr FEES, <br /> PE,vALTIEs,F1vFORCEMEYr CIL NGFS andlor IfOURLYCNARGES associated with this operation will be billed to me at the address identified above as the ACCOUATADDRESS 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 all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <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 address,1 hereby authorize the release of <br /> anv and 211 results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARTMENT as soon as it is available and at the same time it k <br /> provided to me or my representative t <br /> APPLICANT NAME(PLEASE PRINT) William Little SIGNATURE <br /> TITLE Geologist TAxID# <br /> Approved By Date Accounting Office Processing Completed By Date <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT N CHECKS RECEIVED BY WORk PLAdW <br /> FEE:S <br />