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SAN JC <br /> OUNTY ENVIRONMENTAL HEALTH APARTMENT <br /> DATE MER FILE RECORD INFORMATION L*.RF' GREEN FORM <br /> SITE MITIGATION fAkdkP-- <br /> SHADED AREAS FOR EHDnor O OWNER ID# CASE IF U--yNryIIT- iW <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK W OWNER Is cuRREATCYbNF2ewnN EHD <br /> PROPERIYOWNERNAME <br /> FIRST MI LAST PHONE NUMBER <br /> BUSINESS NAME San Joaquin Housing Investment Group LLC EMMLADDRESS <br /> georgia@stand.comcastbiz.net <br /> OWNER HOME ADDRESS 1209 East 8th Street O <br /> CITY StocktonSTATE ZIP <br /> AY 15 2015 CA 95206 <br /> OWNER MAIUNO ADDRESS 1209 East 8th Street HEALTH <br /> ONMENT <br /> MauNGADDRESSCITY Stockton pEfl STATE CA zip 95206 <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION X_ENVIRONMENTAL ASSESSMENT—VOLUNTARY CLEANUP WATER QUALITY HW PIPELINE INVESTIGATION LOP <br /> FACILITYID# INV! AGCouNTID PRVRO# ASBIONED EMPLOYEE LEADAGENCY;EHD_RWQCB,_DTSC_EPA_ <br /> OOLZS©C( 0511{UI( <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: ,��.y�(( <br /> IS THIS A NEW PROJECT LOCATION NOT PREIa <br /> VIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES X1 NO ❑ <br /> BUSINIESS/FACILITY/SITE/PROJECTNAME Multi-Family Housing Facility - Casa De Oasis <br /> SITE ADDRESS/PROJECT LOCATION 1700 South EI Dorado Street SUITE BUSINESS PHONE <br /> CITY Stockton STATE zIP <br /> CA 95206 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KENT KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPRONAL) <br /> MAILINGADDRESSCRY STATE zip <br /> SICCODE APN# COLIMENr: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESSNAME Advanced GeoEnvironmental ATTENTION:ORCARE OF (OPTIONAL) <br /> MAIUNGADDRESS 837 Shaw Road PHONE 209-467-1006 <br /> CITY Stockton STATE OA zip 95816 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE AC OWLED HENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,Aothorized Agent,or Responsible Parry and I acknowledge that all PERM/T FEES, <br /> PENALITES,ENFORCEMENTCHARGEs and/or HOURLYCHARG'Es associated with this project will be billed tome at the address identified above as the AC'COUNTADDREBS for this Site. 1 also certify that all <br /> 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 OIUNNANC6 CODES and/or <br /> STANDARDS and STATE:and/or FEDERAL Laws and REGULATIONS As the undersigned Owner,Operator,Authorized Agent,or Responsible Parry for the project located above under facility/site address,I <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQM COUNTY ENVIRONMENTAL HEALTH DEPARIDSENT as soon as it is available <br /> and at the same time it is provided to me or my representative. L—Y <br /> APPLICANT NAME(PLEASE PRIM) SIGNATURE <br /> TITLE TAX ID# <br /> APPROVED BY DATE ACCOUNTING OFFX:E PROCESSING COMPLETED BY DATE <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK RECEIVED t]l <br /> WORK PIAN PE <br /> FEE:$ <br />