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SmF <br /> San Juin County Environmental Health Oartment <br /> DATE 01 November 201JOWNER <br /> MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> �t �v SITE MITIGATION& LOP <br /> 9H AfA8 END USE O ID# 1� { ("r CASE D (pUNIT IV <br /> OWNER FILE: �THWFM PROPERTY OWNER WOURNIAT101ir CkMww OWNER EHD E1 <br /> PROPERTYOWNEAWWE EUGENE WARNER <br /> First Ml Last PHONENUMaER <br /> BUSINESSNAME EfAAILAoORM <br /> Owner Home Address 372 SOUTH LOCAN AVENUE <br /> city FRESNO STATE CA LP 93727 <br /> Owner Mailing Address <br /> Mailing Address,City OO--{{�� State zip <br /> CORPORATION❑ INDIVIDUALMK PARTNERSHIP❑ FED AGENCY El OTHER❑ <br /> $RL'MITIGATION_ENvIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUAl1TY_HW PIPELINE INVESTIGATION_LOP <br /> FAciuwiD# INV# ACCOUNTID PRM # AssIGNEo EMPLOYEE LEAo AGENCY:EHD�RWQCB_DTSC_EPA_ <br /> zto$`f 379-1-7 o OtO q <br /> FACILITY FILE 0bMPnETE-rW OLLt BUSINESS/FACILITY/SITE <br /> Is this a New Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES OK No ❑ <br /> Is this an EXISTING Business LOCATION bid NEW TYPE Of regulated Business? YES EF No ❑ <br /> BUSINESSIFACKIYISITENAME FORMER BANK; NOT CURRENTLY OCCUPIED <br /> SIEADDRESS 520 NORTH EL DORADO STREET SurrE# BUSMESS PHONE <br /> Cm STOCKTON STATE CALF 95202 <br /> BOARDOFSUPERVISOROISTRICT LOCATION CODE KEY'I KE2 <br /> Mailing Address,' RissWRORYAddbeaa Attention:owCare Ol{6pgmota4l <br /> Mailing Address City STATE zip <br /> SICCODE APN# COMMENT: <br /> orpo32 <br /> THIRD PARTY BILLING INPOI Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESSNAME p BABU SAGIREDDY Attention:owCare Of(tapebeaq <br /> Meiling Address 801 EAST MARCH LANE PHONE 415-990-0125 <br /> CITY STOCKTON STAR CA LP 95210 <br /> forfeas and Charges DINNER FACIIJTYIBUSINESS THIRD PARTY BILLING <br /> Bn. G AND COMPLIANCF AC0a0WLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Autkorized Agent of this Business,and!acknowledge that an PERMIT PEES, <br /> PENALYTPS,ENEORCEMENTCHARGEe and/or HOUNY CWARGM associated with this operation will be billed to me at the address identified above as the ACCOUNTADOa CS for Mu site. I also certify that <br /> all information provided on this application u true suit correct;and Mat ell regulated activities will be performed in accordance with all applicable SAN JDAQUM COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FLDEau.Laws and Regulations. As the undersigned owner,operator,tangent of Me property located at ove fac' /sift address,t hereby euMadze the relwe of <br /> any and all reaule and environmental assessment informations M SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D `� 't u avatla and at the same time it is <br /> provided to me or my representative. ROBERT E. MARTY <br /> APPLICANTNAME(PLEASEPRINT) ADVANCED GEOENVIRONMENTAL, INC SIONATUR <br /> TITLE AGENT FOR MR. SAGIREDDY TAX ID / <br /> Approved By pate Accountlng OIRee Processing Completed SY pate <br /> SITE M'�'nwilON AMOUNT PAID DATE OF PAYMENT PAYMENTT'PE `^O1DTs CNECN#'rr� NEnEIVED BY WORK PLA <br /> NPE" <br />