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i s <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> �� (� n SITE MITIGATION&LOP <br /> smoeo meats Fog EHD UaE ONLY OWNER ID#(�WW-71D CASE# S/2oo71(,87j UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER 18CURRENn.rONFREWITH EHD � <br /> PROPERIYOWNERNAME <br /> FIRST NI LAST PHONE NUMBER <br /> BUSINESS NAME E-MAILADDREH; et:rglQ �-fpylq,('� <br /> San Joaquin Housing Investment Group LLC he, <br /> OWNER HOME ADDRESS 1209 East 8th Street <br /> O"T Stockton STATE CA nP 95206 <br /> OMER MAILING ADDRESS 1209 East 8th Street <br /> MAIUNo ADORESSCOY Stockton STATE CA nP 95206 <br /> ❑CORPORATION ❑INOWIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> � ACILIF# INv# Acccuur lD PRWRO# A991GNEp EMPLOYEE LEAD Ac£NCY:EHD�RWQCB DTSC EPA_ <br /> Fsoq RWN07D -'zusa9ls7 4C."Arny <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> .IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO IX <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES XI NO ❑ <br /> BVSINESs/FACILTTYISITEMROJECT NAME Multi-Family Housing Facility - Casa De Oasis <br /> SITE ADDRESS I PROJECT LOCATION 1700 South EI Dorado Street SUITE BUSINESS PHONE <br /> Crtv Stockton $TATE CAPP 95206 <br /> BOARD OF SUPERVISOR DISTRICT (''T� LOCATION CODE O/ KEYS KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:OR CARE OF(OPTIONAL) <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE APN# d3 ] COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENNFIED ABOVE. <br /> BUSINESSNAME Advanced GeoEnvironmental ATTEMNIN:ORCARE OF (OPTIONAL.) <br /> MAIUKGADDRESS 837 Shaw Road PHONE 209-467-1006 <br /> Cm Stockton STATE CA zip 95816 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNEREI FACILITY/13USINES5El THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: .),the undersigned Applicant;certify that I am the Owner,Operator,Amhor¢edAgent,or Rnpo¢Tlbfe Parry and I acknowledge that all Pinisu Ees, <br /> PENALTIES,ENFORCEMENT CHANGES and/or flooRLYCHARGES moodatal WIM MIS project will be billed tonic at the address identified shoe as the ACCOUNTAzoomss for this Site. I also certify that all <br /> information provided On DSIs application is true and Correct;and that all regulated aetiYitles WIB be performed in accordance\VIM all applicable SAN JOAQUIN COUNTY ORDINANCE CODES anNOr <br /> STANDARDS and STATE.MV0r FEDERAL Lam and REGULATIONS. As the undersigned Owner,Oper000r,Authorized Agent,Or ReVPonsib(e Party for the project located above Under facility/site oddRSs,I <br /> hereby auMorVe the release of any and all results,reports,and Other environmental assessment information N SAN JOAQUIN COUNTY E!p IRONME iTAL H6ALTN DEPARTMENT As soon M it is available <br /> and at the some time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) SIGNATURE <br /> TITLE TAK ID# <br /> APPROVED BY DATE ALWUMINOOFRCEPROCE WCOMPIEIEOBY DATE _ <br /> $ITE MfITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK RECENED BY W RK PLAN PE 1 <br /> ��5� -- <br />