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San Juin County Environmental Health C.aartment i LQn, 1:, <br /> DATE O1 November 2011 MASTER FILE RECORD INFORMATION "MFR" BREEN FORM <br /> (Y SITE MITIGATION & LOP <br /> SHADED AREAS FOR END USE ONLY OWNERRT# 1 -13" <br /> ^13" CASE �QQ �j3Q S� UNIT IV <br /> OWNER FILEPROPERTY OWNER Uwumigornotr CnecirseOWNER C>MsaEL¢TErDxFtLEwaprEHD � <br /> PROPERTY OwNeR NAME EUGENE WARNER <br /> First MI Last PHOMENUMBER <br /> BUSINESSNAME C-MAILAODRESS <br /> Owner Home Address 372 SOUTH LOGAN AVENUE <br /> QXr FRESNO * STATE CA LP 93727 <br /> Owner Mailing Address <br /> Mailing Address Cityryry�� State Zip <br /> CORPORATION INDIVIDUALU PARTNERSHIP El FED AGENCY El OTHER El <br /> Srn!MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FAcILITYID# INV# ACCOUNT ID OB ASSIGNED EMPLOYEE LEAD AGENCY:EHD,,�,_RWQCB_DTSC_EPA— <br /> ;L1 10g'5 <br /> PA_;L19g"9 3-79i-7 0S3 (--7(b (�qq <br /> FACILITY FILE CbMPLEWTFWFGZL0XM BUSINESS IFACILITY ISITE WFORMA1T INC. <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES U No ❑ <br /> Is this an EXISTING Business LOCATION but NEW TYPE Of regulated Business? YES P9K No ❑ <br /> BUSINESSIFACILUYISITE NAME FORMER BANK; NOT CURRENTLY OCCUPIED <br /> SITE ADDRESS 520 NORTH EL DORADO STREET sunE# BUSINESSPHONE <br /> CITY STOCKTON STATE CA" 95202 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEPT KEY2 <br /> Mailing Address WWFERE ffvavFhs:=rAdtlbeSRs Attention:wCare Of raistImmV <br /> Mailing Address City STATE Zip <br /> SICCODE APR# COMMENT: <br /> orpo32 11 1 <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESSNAME p BABU SAGIREDDY Attention:arCare Of{bpu6vrag <br /> Mailing Address 801 EAST MARCH LANE PHDNE415-990-0125 <br /> CITY STOCKTON STATE CA 7jP 95210 <br /> forfees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANLF A(WiOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Ol Yom,or Authorized Agent of thin Business,and 1 acknowledge that an PERMfTf1ES, <br /> PPNALRE$ENPoFCEM1IEM'CHAR46S and/or HOURLTCIGUGES associated with the operation will be billed to ,at the address identified above as the ACCOUNTADOREYS for this site. I also arfify that <br /> all information provided on this application is Our end correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQM COUNTY Ordinance Coda and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations.As the uudenigned owner,operator,or agent of the property located at ave Tac" /site address,I hereby authorize the release of <br /> any and an results and environmental assenmest information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D ENT IS atit is avails 1 .and at the same time it is <br /> provided to me or my repraemattivs ROBERT E. MARTY <br /> APPLICANT NAME(PLEASEPRINT) ADVANCED GEOENVIRONMENTAL, INC SIGNATUR <br /> TITLE AGENT FOR MR. SAGIREDDY TAX ID <br /> Approved By Data Accounting OMca Processing Completed B Deb I <br /> SITE MITIGATION AMOUNT P/\AII-D nATE OF PAYMENT PAYMENTTYPE RECEIPT# QHEDK# RECEIVED BY WORK PLAN PE <br /> FEE:I_ 3�'5 II _ I ✓ 5;` 67 2t� 024.5 <br />