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San Jo4, kin County Environmental Health Def rtment <br /> DATE 11/10/2014 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION &LOP <br /> SHADEDAREA9 FOREHDUSe ONLY 0ljongv3/1 S. �PCC,7/ oSZ UNIT IV <br /> OWNER IDY KI(/UK J(( CASEY p 7 <br /> DNINERFILE:COMPLErE7NEFOLLOW/NG PROPERTY OWNERINFORMAT/OFN1CNECa(FDINNERCURREMAYONFaEWITH EHD <br /> PROPERTY OWNER NAME "- <br /> FOSt MI Last `PHONE NUMBER <br /> BUSINESS NAME Nippon Sheet Glass Cc Ltd EMAIL ADDRESS <br /> Owner Home Address500-East Louise Avenue ALTH <br /> PERMIT/SERVICES <br /> city Lathrop STATLAA LP 95330 <br /> Owner Melling Address <br /> Melling Address City state Zip <br /> ppII <br /> CORPORATIONyy INDIVIDUAL PARTNERSHIP 11 FED AGENCY El OBER E) <br /> SITE MmQAT1om_ENVIRONMENTAL AssE ;I ENTFX VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILRY IDY iHNY ACCOUNTIG PR YIRoe FrT' pc4sP' I -n r` �` f - * - <br /> af,, a Tito y a�tAAA+ EHQ [2pat�,g SCh. -E,g <br /> }t'F�An�"JII��C,<>''�}�k <br /> 'ACILITYFiLE COMPLETE HEFOLLOW/NGBUSINESS/FACILITY/SITE INFORMAPON. <br /> Is this a NEW Business LOCATION not previously regulated by the ENWRONMENTALHEALTH DEPARTMENT? Yes ❑ No R( <br /> Is this an EZIS'ING Business LOCAnONbuta NEW TYPE or regulated Business? YEsA No ❑ <br /> BUSINESs/FACILITY/SRENAME Pilkington - North America - Lathrop c/o Reynolds and Brown <br /> SITE ADDRESS sunrl BUSINESS PHONE <br /> 500 East Louise Avenue <br /> CITY Lathrop STATE CACP 95330 <br /> BOARD OF SUPERVISOR DISTRICT U� LOCATION CODE V� Keri KEY2 <br /> Melling Address/FO/FFERENTIrotn Fee1lNyMkimss AttenUcm:or Care Of(optional) <br /> 1200 Concord Avenue, Suite 200 Dana Parry <br /> Mailing Address City Concord STICA aP 94520 <br /> SIC CODE APNY 198-120-08 and 09 COMMENT: Soil borings <br /> 'HISID PARTY BILLING INFO: Complete if Billing Party Is different from Property Owner ol-Facility Operator iden5led above. <br /> BUSINESS NAME c/o Reynolds and Brown AUnntion:OrDara Of (OPNOna/I Dana Parry <br /> Mailing Address 1200 Concord Avenue, Suite 200 PHONE <br /> Cm Concord STATE CA LP 94520 <br /> ACCOOwrAOOREEa for fees and Chargee OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> ILLINC AND COMPLIANCE ALRNOWLEDCMENT: 1,the undersigned Applicanq certify that I am the Owner Operator,or ANrhodoedAgent of INs Business,and I aclu oaldge fl al all FsAAnrFess, <br /> ENALTYLe,ENFORMOINTCHAROrtad/or flouR rCMIGEr associated with thla operation will be baled tome atthe address identif`iHed above as theACQQL ,,lot) for this site. I also certify lull all <br /> formation provided on this application Is time Rod ovech and that ad/regulated activities will be perfarmd In acmdance/ I applicable SAN JOAQUIN COUNTY Ordinance Codd and/or <br /> ,am ards and STATE and/or FYDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property loo a[1 abort faCHIV .ddra i;,I hereby authorise the release of <br /> D and all results and environmental.,.,,.at information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH EPAR ENT at sou .'I is jvaliable and at the same time It is <br /> ,ovidcd to me or my represenmHve. t <br /> APPLICANT NAME(PLEASE PRINT) Dana Parry SIONATIIRE �/ n�s - <br /> TITLE President- CEO TAXID# <br /> Approved By Data ACCDNOWg Dtnee Proeaesing Camplalad By Data <br /> SITEMITIGATION AMOUNTPAID DATE OF PAYMENT PAYMENTTPE RECEIFTY CHECK# RECEIVED BY :.WORNPWtY �}1 r <br /> C�Y 4 VC,.1 <br /> FEES 4Q 31U ll-fcJ'1`I �!#fJet /O"72.y �orAlv7Gf2 ''�.. / O.._;: . <br />