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SAN JUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION& LOP <br /> SHAD D FOR HD USE ONLY <br /> OWNER ID# CABE0 UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNERI RESPONSIBLE PARTY INFORMATION: CHECKS'014W£RISCURRENTLYONFaewirHEHDEl <br /> PROPERTY OWNER NAME <br /> FIRST Ml LAST PHONE NUMBER <br /> BUSINESS NAME EMAIL ADDRESS QCr I <br /> San Joaquin Housing Investment Group LLC 9a QfAm-CO 'i+ol <br /> OWNER HOME ADDRESS 1209 East 8th Street <br /> Cm Stockton STATE LP <br /> CA 95206 <br /> OWNER MAILING ADDRESS 1209 East 8th Street <br /> MAILING ADDRESS CITY Stockton �"TE CA nP 95206 <br /> O CORPORATION O INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY <br /> ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION__LOP <br /> FACILm ID# INV# ACCOUNT ID PR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_ `L. RWQCB_DTBC_EPA_ <br /> ^IO/1NRA� <br /> FACILITY FILE:COMPLETE BUSINESS I SITEI PROJECT INFORMATION: ,Mu <br /> IS THIS ANEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES Cl No IN <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT NEW SCOPE OF WORK? YES X1 NO O <br /> BUBINE88IFACILmISKEIPIIOJECT NAME Multi-Family Housing Facility - Casa De Oasis <br /> SITE ADDRESS I PROJECT LOCATION 1700 South EI Dorado Street SUITE III BUSINESS PHONE <br /> Cm Stockton <br /> STATE CARP 95206 <br /> BOARD OF SUPER VISOR DISTRICT LOCATION CODE O/ KEY1 KET2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF f0.^TRMNL) <br /> MAILING ADDRESS Cm STATE LP <br /> SIC CGDE APN# '�., 03 / 11 COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME Advanced GeoEnvironmental ATTENTION:ORCARE OF (CPTro ) <br /> MAILING ADDRESS 837 Shaw Road PHONE <br /> 20967-1006 <br /> Cm Stockton STATE CA LP <br /> 95816 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNERO FACILITY/BUSINESSO THIRD PARTY BILLING <br /> BILLING AaD COMPLIANCE ACRNOWLEDGMENTI 1,the undersigned Applieant,certify that I am the Owneq Operator,A.Ih.,ked Agent,orR-;NmNfb&Parry and!aclmowledge that all PERMIT FEES, <br /> P£NALUES,ENFORCEMENT CHARGES and/or HOURLYCHARGES associated with this project Dill he billed to meat the address Identified above US the AC'COUNTADDR£SS for this Nine. I also certify Mat all <br /> mforma on provided on this applieHhon is tree and correct;and that all regulated activities will be performed N accordance with all appll®ble SAN JOAQUIN COUNTY ORDINANCE CODES and/or <br /> STANDARDS and SrATE and/or FEDERAL Laws and REGULATIONS. AS the Undersigned(AUneq Ofvramr,Authorl'IedAgenq or Responsible Poor,for the project heated above Under facility/site address,l <br /> hereby authorize the release of any and all results,Rpores,and ogler a iro mental alloNsonent hlforrom lon to SAN JOAQUIN COUNTY E! ONME TAL REALM DUARTMENT M soon as It IS available <br /> and at the same time it's provided to me or my represenmfive <br /> APPLMANT NAME(PLEASE PRINT) SIGNATURE <br /> TITLE <br /> TAz ID# <br /> APPRWED BY DATE ACCOUNDNOOFr10EPROCESNNOCOMPLETEDBY DATE <br /> FRE MITIGATION I AMOUNT PAID DATE OF PAYhMENT PArYMENT TYPE RECEIPT# CHECK III RECEIVED BY W RKPUN PE. <br /> FEE:S �AT(� w -1�AY L-N(�K 112G 3 C fuv' T�, ..Sp <br /> 1 O <br />