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San Jc iquin County Environmental Health Doaartment <br /> DATE 06/24/2014MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR END USE ONLY OWNER ID# CASE It UNIT IV <br /> OWNER PILE : CommETETHEFOLLOW/NG PROPERTY OWNER /NFORMA7tOM cREcs/v OWNER CuRRENrcrommEwRx END Ll <br /> PROPERTY OWNER NAME Robbie Naive / 408 \ 410-5220 <br /> Rol MI Last \PHONE NUMBEN <br /> BUSINESS NAME EMAIL ADDRESS <br /> 24 EIRS Gas N/A <br /> Owner Houle Addrea9 <br /> P . D . Box 20006 <br /> City San Jose STATE Zip <br /> C!A 95160 <br /> Owner Melling Address same as above <br /> Melling Address City State Zip <br /> CORPORATION ❑ INDIVIDUAL D PARTNERSHIP [-I FED AGENCY ❑ OTHER El <br /> SITE MITIGATION _ lENVIRONMENTALAsSESSMENT —VOLUNTARY CLEANUP —WATER QUALITY HWPIPELINE INVESTIGATION _ LOP <br /> FACILITY ID # INV# ACCOUNT ID PR #IRO # A89IGNED EMPLOYEE LEAD AGENCY: EHD_RWQCB_ DTSC _ EPA_ <br /> FACILITY FILE COMPLETETHEFOLLOW/NG BUSINESS / FACILITY / SITE /NFORmw-tom' <br /> Is this a NEW Business LOCATIONnot previously regulated by the ENVIRONMENTALHEACTHOEPARTMENT? YES ❑ No El <br /> IS this an EXISTING Business LOCATION but a NEw TYPE Of regulated Business? YEs ❑ No ❑ <br /> BUSINESs/FACILITY/SITE NAME Quick N Save 41 <br /> SITE ADDRESS SUITE# BUSINESSPHONE <br /> 1901 Guth El Faragostreet <br /> CITY 1 <br /> :Stockton CATATE YS205 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE Kul KEY2 <br /> Melling Address IT DIFFERENTrmmFacilityAddmw Attention: orCare Of (optional/ <br /> F0 . Box 20BOG <br /> Melling Addreas CRy STATE Zip <br /> San Jose CA 95160 <br /> SICCODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orfacility Operator identif/edabove. <br /> BUSINESS NAME Advanced Geosw,ronmeneal Inc Attention: orCare Of (opffonag <br /> Daniel Villanueva <br /> Melling Address PHONE <br /> 837 Shaw Road <br /> Cin STATE ZIP <br /> Stockton CA 95215 <br /> AcaoaATAaamais for fees and charges OWNER FACILITY/BUSINESS HIRD PARTY BILUN <br /> BILLING AND COMPLIANCE. ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Aut/mrized Agent of this Business, and I ac wedge that all PFmUrF Es, <br /> PENALUES, s FORCEAIENTC AXES and/or HovYzyC URGES associated with this operation will he bitted to me at the address identified above as the AccouvrAnas ssfor this site. I also certify that <br /> all information provided on this appficafion is true and correct, and that all regulated activities will he performed in accordance with all applicable SAN JOAQum COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or h2oERAL Laws and Regulations. As the undersigned owner, operator, or agent of the property located at the above fadhty/site address, I hereby authorize the release of <br /> any Rud all results and ewironmenfal assessment infmmaton to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same fife it is <br /> provided to me or my representative <br /> APPLICANT NAME (PLEASE PRINT) Daniel Villanueva SIGNATURE <br /> TITLE Project Geo e t TA x ID # N/A <br /> Approved By Data I Accounting Office Processing Completed By Data <br /> SITE MITIGATION AMOUNTPAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK # RECEIVED BY WORK PLAN PE <br /> FEE: $ <br />