My WebLink
|
Help
|
About
|
Sign Out
Home
Browse
Search
SITE INFORMATION AND CORRESPONDENCE
EnvironmentalHealth
>
EHD Program Facility Records by Street Name
>
C
>
COPPEROPOLIS
>
10848
>
2900 - Site Mitigation Program
>
PR0536777
>
SITE INFORMATION AND CORRESPONDENCE
Metadata
Thumbnails
Annotations
Entry Properties
Last modified
6/18/2019 11:26:06 AM
Creation date
6/18/2019 11:09:46 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
SITE INFORMATION AND CORRESPONDENCE
RECORD_ID
PR0536777
PE
2960
FACILITY_ID
FA0021126
FACILITY_NAME
FORMER COUNTRYSIDE MARKET
STREET_NUMBER
10848
STREET_NAME
COPPEROPOLIS
STREET_TYPE
RD
City
STOCKTON
Zip
95215
APN
10311006
CURRENT_STATUS
01
SITE_LOCATION
10848 COPPEROPOLIS RD
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
Scanner
SJGOV\wng
Tags
EHD - Public
There are no annotations on this page.
Document management portal powered by Laserfiche WebLink 9 © 1998-2015
Laserfiche.
All rights reserved.
/
185
PDF
Print
Pages to print
Enter page numbers and/or page ranges separated by commas. For example, 1,3,5-12.
After downloading, print the document using a PDF reader (e.g. Adobe Reader).
View images
View plain text
SAN*UIN COUNTY ENVIRONMENTAL HEALTH ARTMENT <br /> « 99 GREENFORM <br /> DATE /oro r2 MASTER FILE RECORD INFORMATION MFR <br /> SITE MITIGATION & LOP <br /> OWNER ID# �[ X11 GI//f/'0 07 UNIT IV <br /> S EHDU EO V /\\� �I 1�� CASE# - „JI\VV � 8 <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY <br /> INFORMATION: CNECx jr OWNER IS CURRERRY00 FILE wirH EHD 1� <br /> PROPERIYOWNERNAME zzu //�L�r•T�Q/ (RoS)993-379 <br /> v FIRST MI LIST PHONENUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> OWNER HOME ADDRESS <br /> CITY S7/OG�tOr• <br /> J / / sTC� LP9Sz�S <br /> OWNER MAILINGADORES9 <br /> MAILING ADDRESS CITY ! STATE ZIP <br /> -A 9szaS <br /> ❑CORPORATION ysf INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT "-"- ' .EAN _WATER QUALITY_HW PIPELINE INVESTIGATION_LOP_ <br /> FACILITY ID# INV# ArrnUUTI ASBIGNEG EMPLOYEE LEAD AGENCY:EHDRWQCBDTSC_EPA <br /> txo77oti\ � ,C)3 e�ssc�» �oKwRy <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PR ECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No 2[ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES No ❑ <br /> BUSINESSIFACILRYISITEIPROJECT NAME t ,y <br /> SITE ADDRESS I PROJECT LOCATION �f SUITE# BUSINESS PHONE <br /> /OyYt <br /> CITY STATE LP <br /> S'p'a cG-'fo.+ eA 95y7-02 <br /> BOARD OF SUPERVISOR DISTRICT q LOCATION CODE / KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPwOML) <br /> MAILING ADDRESS CRY STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> to 3- Ito- oS 11 <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME -ry SOuiCG �/4 �pJ���C• /'�1 ATTENTION:ORCARE OF (OPT/ONAL) <br /> MAILING ADDRESS 9yY hclou��M2 /cL1. S ` I I (PHONSE <br /> o)272-r/J-UU <br /> CITY STATE LP <br /> G.STT zea//e CA 9s9Y9 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER FACILITY/BUSINESS❑ THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,Certify that 1 am the Owner,Operator,Autboricad Agen4 or Responsible Party and I aclolawledge that all P£IORTFEES, <br /> PEN TLFs,ENFORC£Atew CRdRO£S and/or Hounr CH,,RCES associated with this project will be billed to me at the add revs identified above as the ACCOUATAUDR£4s far this site. 1 also certify that all <br /> information provided on this application is true and correct:and that all regWated ettivides will be performed in accordance with all applicable SAN JOAQUIN COUMV ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the uadersigned Owner,Operatar,Authe i adAgeny ar Respmrsible P r y for the project located above under facility/sire add revs,1 <br /> hereby authorize the release of any and all results,reports,and other environmental assessment infornsatlon to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as aeon as it is available <br /> and at the same time it is provided to me or my representative <br /> APPLICANT NAME(PLEAS E PRINT) SIGNATURE <br /> TITLE S->~a�f' gefeh�:r�' TMID# 77-Oy669Set <br /> APPROVEDBY DATE ACCODNTINO OFFICE PROCESSING COMPLETED BY DATE <br /> SITE,MITIGA ON AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORN PIAN PE <br /> 'J <br /> FEE:A 9 ✓ / <br />
The URL can be used to link to this page
Your browser does not support the video tag.