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I <br /> i <br /> San Joaquin County Environmental Health Department <br /> DATE 2/3/2015 MASTER FILE RECORD INFORMATION fr MFR» GREENFORM <br /> SITE MITIGATION & LOP <br /> SHADED AREASEHDU8E O Y OWNER IO# CASE # 5�7//t/6 � UNIT IV <br /> OWNER FILE : COMPLETE THEFOLLOWINGPROPERTY OWNER /NFORMATION.' CNEcKtF OWNER CexxeurzvouraewrrH EHDEl <br /> PROPERTYOWNERNAME Sharri Keyes ( 01.470 . 8187 <br /> First MI Last PHONENUMBER <br /> BuslNEss NAME E-MAILADDRE83 <br /> PS Marina 5 <br /> Owner Homo Address <br /> City STATE ZIP <br /> Owner Mailing Address 11530 West Eight Mile Rd . <br /> Melling Address City Stockton Stele CA �1p95219 <br /> CORPORATION El INDIVIDUAL ❑ PARTNERSHIP ❑ FEDAGENOY ❑ OTHER 11 <br /> SITE MITIGATION _ ENVIRONMENTAL ASSESSMENT EVOLUNTARY CLEANUP _ WATER QUALITY _ HW PIPELINE INVESTIGATION _ LOP IY I <br /> FACILITY log IHV# ACCOUNTID PRIV a AsSIGNEDEMPLOYEELEAD AGsxoY: EHD�RWQCB_ DTSC_EPA_ <br /> d 301 #`YAEAfL94 <br /> FACILITYFILE COMPLETE THEFOLLOW/NG BUSINESS / FACILITY / SITE /NFORMATloAV <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an ExiSTING Business LOcATIoNbuta NEWTVPE of regulated Business? YES ❑ No <br /> BUaSums)FACILaY1sire NAME PS Marina 5 / King Island Resort <br /> Sm AOOREss SUITE# BUSINESSPHONE <br /> 11530 West Eight Mile Rd 209.477.5364 <br /> STATE zip <br /> DRY Stockton CA 85219 <br /> BOARD OF SUPERVISOR DISTRICT cI LOCAnog;CODE VI Kul KEY2 <br /> Mailing Address ffDYFFERENrfmm Fao1J*Address Attention: orCare Of topt/onoo <br /> Mailing Address City STATE ZIP <br /> SICCODE APN0 � / _ / �b COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner Or Facility Operator identifiedabove. <br /> BUSINESSNAME Cardno Attention: orCare Of (opf hall) <br /> MallingAddress 1117 Lone Palm Ave. , Suite 201 B PHONE 209 . 579 . 2221 <br /> DIT° Modesto STATE CA 2" 95351 <br /> Acca rurAODRESB for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKV01VLEDGAIENT: 1, lire undersigned Applicant, certify that I tan the Onner, Operaror, or Andarlud Agent or this Business, and I ncletan'ledge the[ all PER.II[TPEEs, <br /> PENAIXET,ENFORC£aaEATCHARGEA'nlld/or HOUa1.r CHAR(;Esassaciuled w'ilh (his operation will be billed tonic at the address Identified above .as the 11MOVATARDRE.Y.e for this site. I also certif), Ilial <br /> all informalioa provided on [his application is true and correct; and that all reguinled ac(ivilies will be Performed in accordance with nil .applienble SANJOAQUIN CODNIV Ordinance Codes mrd/or <br /> Standards and STATE earlier FEDERAL Laws and Regulations. As the undersigned owner, operator, or ngrn[ of the property located at lire above facility/site address, ) hereby authorize (lie release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT is soon as it is available and of [lie same has it is <br /> provided to meormy representative. <br /> APPLICANT NAME (PLEASE PAINT) Jeanne Homsey SIGNATURE _ <br /> b <br /> TITLE Branch Manager TwtID # 499408 <br /> Approvedey Dale AncounsnB ORice Prxeealne Complelede Dela <br /> SITE MITIGATIO—N/ AMOUNTPAIO DATEOF PAYMENT PAYMENTTYPE RECEIPT# CHECK # RECEIVED DV WORK PIAN PE <br />