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pfa�l— <br /> San Joaquin County Environmental Health Department <br /> DATE 03 Sanuary 2012 MASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> SITE MITIGATION&LOP <br /> Sa END D«< OWNER IW CASES Ske) UNIT IV <br /> OWNER FILE:COMPLErE 7NEFOLLOWINO PROPERTY OWNER/NFORK4770N.' ouA Naytya, E WEND <br /> paoPlamOvmeI NAME EUGENE WARNER <br /> Fifst MI LSst PNDNe NINem <br /> BIErIe98 HAZE EaIALLAooaEEs <br /> cm—He" Add— 372 SOUTH LOCAN AVENUE <br /> CRY FRESNO STATE CA LP 93727 <br /> OiNrlsr(AMllre Addws <br /> 11aIlYg Address CKY Stet Zip <br /> CORPonATION❑ INDNIDUALU PARMEP9NIP❑ FED AeeNCY❑ OrHeR❑ <br /> SrrE MRIOATeN_ENviR0NM1NTAL At13lslYMEtrr_VGLBNTARr CLEANuP_WATdt QDAurV_HW PIRuNE INvissneAT10N_LOP <br /> FAcIUTY IO# Iwo AccouxrlD RO/ AgeIONm EMPLOYEE LEAo AoENcr.EHD_�RWOCB_DT$O_EPA_ <br /> 3-19-1-7 05"3G-�r0 /(095 <br /> FACILITYFILE CohvLE THEFotLowwBUSINESS/FACILITY/SITE AVFoR#wmm <br /> Is this a NEW Business LODATIDN not previously regulated by the Emagot11ENfAL HEALTH DEPARTMENT? YES ZJK No ❑ <br /> Is this an ExwMo Business LOCATION but a NEW Type of repiald Budneaa? YEE IK NO ❑ <br /> SueslaelFgaiLaV/$nENAME FORMER BANK; NOT CURRENTLY OCCUPIED <br /> 8"ADOMEse 520 NORTH EL DORADO STREET SlAE# BDetEsspHoNE <br /> O'^ STOCKTON STATE CAS 95202 <br /> BOARODF SUPFINIBOR Dismlcr LOCATION Coos KEYt KEs2 <br /> EdatIsg Address/YDIFFERENTdenn FmAfffyAddm" Attention:o Care Of(Opbbna9 <br /> Mallbg Address CBy STATE zip <br /> $1000°1 - APN# 39 G G 0 3 2 <br /> THIRD PAK"BILLING INFO: Complete if Billing Party Is different from Property Owner orFacility Operator/dentlRed above. <br /> Ea8HF8eNAME P BABU SAGIREDDY AlEnklare 0-Care Of(4M*W <br /> MERV Addy 801 EAST MARCH LANE PHONE 415-990-0125 <br /> GTI STOCKTON STATE CA ZP 95210 <br /> AggaMAgam forfaas and chargee OWNER FACILITY/BUSINESS TNRD PARTY BILLING <br /> 8ll,lAKr,ANOCOMPLIANC ACKNOWLEDGMENT: f,Me undersignrd Applieant terrify Met 1 am Me/toner,Ihxrnrnr,or ANdmrked ASent of this Busitlesn,and 1 echnowlNge that ea PERa/D FEF.F, <br /> PENALnu,ENFO EmPNTCNARGESand/or ROURLYCHAR,Eaaaneinl<d with Mooperadoowill be billed 10 meal theaddrewideneerd above as I1eAIVOUNTAOORES4 for Ihirrife 1 aho eerliry that <br /> ell infor arioa provided on this vp,lie.d..u true and mlrxt;and that oil Melated serivnka will be performed In aceordane with all applkoMe sAN JOAttum Color tv Ordinance Codes and/or <br /> bloodstain and mn and/or FEDERAL Laws and Regulations. As the undereigned ow,Nr,operator,or agent of the properly located at the above facility/aIle addraa,l hereby authorize the rehear of <br /> any and all reaulb and environmental aumment inforllulion to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR EHT as sooa as it k available and at the tame ne it is <br /> provided to me or my representative. ROBERT E. MARTY <br /> APPLICANT NAME(PLEASE Flat )ADVANCED GEOENVIRONMENTAL, INC SloNATVR! <br /> TOLE AGENT FOR MR. SAGIREDDY TAX ID# <br /> Dab GISSE .... p Z <br /> SrTpATON ANOOIITPAID DATEOPPAYMENT PAYMEtrr TYPE REals"S CHECK# REcaveOBY WORK PIAN/PE <br /> FEE:r = p\,q S <br />