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San Akin County Environmental Health Dl( artment <br /> DATE11 11/10/2014 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> �Y SITE MITIGATION&LOP <br /> SHAVED EHDU O WHEN IDB CASERL C"?0152 UNIT IV <br /> R 7 J <br /> DWHER FILE:ComPCE7FTHEFoLLowlNc PROPERTY OWNER INFoRmATIoN: CHECKIF OWNER CORKE <br /> PROPERTY OWNER NAME <br /> FIrst MI Latif PHONE NUMBER t� j <br /> BUSINESS NAME Nippon Sheet Glass Co Ltd E-MAILADDRESs <br /> Owner Home Address 500 East Louise Avenue "ALTH <br /> RERPAITISERVIOES <br /> city Lathro <br /> pBTAT¢vA L' 95330 <br /> Owner Melling Address lr <br /> Mailing Address City <br /> state Zip <br /> CORPORATIONS INDIVIDUAL❑ VVvv PARTNERSHIP❑ FEDAGENCY❑ OTHER <br /> ;ITE MITIGATION_ENVIRONMENTAL ASBEsa MENTXX VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP_ <br /> FACILfTY IrID BtI INV# ACCOUNTID PROIRD! IN +9'r"N e,`c p�'D '. "� Eli r "( CBF SC�.r' ` h <br /> MON.�3�'i���.` r+rF its i/f5'��..'�' <br /> =ACIUTYFILE COMPtErETHEFOLLOw/NGBUSINESS/FACILITY/SITE INFORMAnON' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes ❑ No u <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YEsXX No ❑ <br /> BusINuWFAcn TIT/Sne NAME Pilkington - North America - Lathrop c/o Reynolds and Brown <br /> SITE ADDRESS SURE# BUSINESS PHONE <br /> 500 East Louise Avenue <br /> Cm Lathrop STATE C& 95330 <br /> BOARD OF SUPERVISOR DISTRICT �'A.> LocATIDM CODE 0-7 1 <br /> Kerl KEY2 <br /> Melling Address ItOIFFEREAVrfrom FactlltyAddmas Attention:orCare of(optlonal) <br /> 1200 Concord Avenue, Suite 200 Dana Parry <br /> Meiling Address City Concord b7AT'CA 94520 <br /> SIC CODE 198-120-08 and 09 DOMMEMrt Soil borings <br /> ' 11 <br /> HIRD PA rry BILLING INFO: Complete if Billing Party is different from Property Owner orFaclllty Operator idenb'(edabove, <br /> BUSINESS NAME c/o Reynolds and Brown Atteneomorcare Of fOPtlonalf Dana Parry <br /> Meiling Address 1200 Concord Avenue, Suite 200 PHONE <br /> CITY Concord STATE CA L" 94520 <br /> Ac=VAMAnnrtFca for fees and charges OWNER FACILfiY/BUSINESS THIRD PARTY BILLING <br /> ILLINC AND COMPLfANa ACKNOwt.EDCMENT: 1,the undersigned Appacan4 cerdfy that I am the Owner,Opemmr,orduthoriudAgent of!IVIS Bulness,and 1 acknowledge Balsa PEaswrFEEs, <br /> tvurrsr,ENFDxeurswrOuaers and/or 110U.U.Y6 Ac=AssociNed with Wls operation sill be baled tome at the address Identieed obeys u the dCCODATADDR=for Ddb she. Ialsoc:rtify Nat AI <br /> formadon pmvldsd on this appButioo Is true and enmaen and that all regulated activide,waI be performed N acurdanm s appliuble SAN JDAQUIN COUNTY Ordinaoce Cod.and/or <br /> andards and STATE and/or FxoeR Laws and Regidations. As the undersigned owner,openlor,or agent of the prop.Ty loo at t above fadilly/s dd",I benby authorim the release of <br /> ty and all resWtr and enNronmental Assessment Information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHEPAR ENT u soofi u it is vallsble and at Nut same d.,It is <br /> ,oNJW to ma or my represemstire. + I <br /> APPLICANT NAME(PLEASE PRINT) Dana Parry SIGNATURE /ti lj{/litib <br /> TITLE president - CEO TAX ID# I •') , <br /> Appmwd By Data AccnunU,p OTica Praeeuing Complatad By / Data <br /> SITEMITIG4ATION AMDONTPAID DATE OF PAYMENT PAYMEHTTYPE RECEIPT# CHECK RECEIVED BY :.WOR4k <br /> FEE:$ SO Iv lI'IU-1�l I{Q�� /O'7 G.q I:OC-W7&4Z ��.. l O <br />