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San Joaquin County Environmental Health Department <br /> DATE OS March 2012 MASTER FILE RECORD INFORMATION"MFR" �F2�SITE <br /> GREEN FORM <br /> SITE MITIGATION & LOP <br /> R A SFOREHDUSEONLY OWNERIO# CME# DO L.Y' S�� UNIT IV <br /> OWNER FILE:[oAIPLETE7NEFOLLGWINO PROPERTY OWNER lwommnow CHECK/FOWNER CURRENRYONFILEmomEHDEl <br /> PROPERIYOWNERNAME EUGENE WARNER <br /> Fist MI Lest PHONE NUMBER <br /> EH4UILA oivsss <br /> BUSINESS NAME <br /> OwnerH—Add— 372 SOUTH LOCAN AVENUE <br /> City FRESNO STATE CA I LP 93727 <br /> Owner Mailing Address <br /> Mailing Address City Stab Lp <br /> CORPORATION❑ INDWIDUAL L_}• PARTNERSHIP❑ FED AaeRCY❑ OTHER <br /> SITE MI716ATION_ENVIRONMENTAL ASSESSMENT_VOWNTARV CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY I D# INA 11 Acccuar lD P O# Is NEDEMPLOYEE LEAD Aooi n:1:! 1111[111 RWOCB_DTSC_EPA <br /> p�.io8! D3-14�7 0 3bTlt7 /(vel <br /> FACILITY FILE COMPLE7E THEFOLLOW/NG BUSINESS I FACILITY I SITE/NFORMAT/ON: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES N.X <br /> Is this an EXISTIND$Usbness LOcAnON but a NEW TYPE of regulated Business? YES No <br /> BUSINESSMACIUViSITE NAME FORMER BANK; NOT CURRENTLY OCCUPIED <br /> Sr1EADUREsa 520 NORTH EL DORADO STREET SuBE# BUSINESS PHONE <br /> CITY STOCKTON STATE CALP 95202 <br /> BOARD OF SUPERVISOR DIane1CT LOCATION CODE KEPI KEY2 <br /> Mailing Address MDIFFERENTfrom FwMWAddrese AlbuTWn'trrCare Of(ep#onstt <br /> Melling Addreas CNy STATE zip <br /> SIC CODE APN# 1139, �()- y 2 COMMENT: 7 crp—/ r� excs <br /> THIRD PAtm BILLING INFO: Complete if Billing Party is different from Property Ownerr�orpFacility operator identfed above. <br /> BUSINESSNAME p BABU SAGIREDDY Atbntbn. srOare Of(opawte/1 <br /> Mailing Address 801 EAST MARCH LANE PHONE 415-990-0125 <br /> CITY STOCKTON STATE CA IJP 95210 <br /> AGI:Bla2A�R69.4 for fees and Charges OWNER FAciuTYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLL NCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that an PEassIT FEES, <br /> PENALTIES,ENFOECEMENTCRARG£S and/or RDDELYCRAEGEs associated with this operation will be billed to me at the address identified above As the A6 OUNTADDRM for this site. 1 abo certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or PFDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/sib address,I hereby authorize the release of <br /> R MENT as soon as <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAit is available and at the same time it is <br /> provided to me or my representative. ROBERT E. MARTY <br /> APPLICANT NAME(PLFASE PRINT)ADVANCED GEOENVIRONMENTAL, INC 810MMRE <br /> TITLE AGENT FOR MR. SAGIREDDY TAxID# 1 <br /> Approved eyDeb Acecuneng Office PrommulegCompltad By Date I IZ <br /> SITE Min"TION ANOUNTPAID MIEOFPAYMENT PAYMENTTYPE RECEIPTS CHECK# RECEIVED BY WORK P(�IAN/PE <br /> FEE:; /// �' h 9 v <br />