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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER IDN CASE N UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CNEOKlFOWNERISCORRENTLYONFILEW/rN EHD <br /> PROPERTY OWNER NAME Steve - <br /> Valentine > 09) 609-7482 <br /> FIRST MI LAST PHONE NUMBER <br /> BUSINESS NAME jwees QgrounClzeroanalysis <br /> OWNER HOME ADDRESS 201 Marc Avenue <br /> C"Y Stockton STATE CA zIP 95207 <br /> OWNER MAILING ADDRESS Same <br /> MAILING ADDRESS CITY y5}� STATE ZIP <br /> ❑CORPORATION ❑INDIVIDUAL [I PARTNERSHIP ❑GOVERNMENT AGENCY N*ESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY 10 N INVN AccouNT ID PR N/RO N A6ewNEo Elit►LOYEE LEw AeENDY:EHD_RWQCB_DTSC_EPA_ <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 (� <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES [21 No ❑ <br /> BUSINESS/FACiUTY/SREIPROJECTNAME Steve & Genes Service <br /> SITE ADDRESS l PROJECT LOCATION 2 315 N El Dorado Street SUITE N BUSINESS PHONE <br /> CITY Stockton STATE CA ZIP 95204 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEv2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS 201 Marc Ave ATTENTION:ORCARE OF(OPTIONAL) <br /> MAILING ADDRESS CITY Stockton STATFcA ZI► 95207 <br /> SIC CODE APN N COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ATTENTION:ORCARE OF(OP)ONAL <br /> MAILING ADDRESS PHONE <br /> CITY STATE ZIP <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER FACILJTYIBUSINESS❑ THIRD PARTY BILLING❑ <br /> BILLING.aro Cuw•LbucE ACI:�ow LEIxsIEv r: 1,the undersigned Applicant•cerli fy[hal 1 am the Onwer,(JPerator.Authori edA,Cent.or Reslmnsihle Parry and 1 acknoss ledge that all PL'R.It1T FL&T, <br /> PLVALTlr_S,P'AIORCEME\T CIL(RGES and/or Hot RLV otwt;&c associated with this project will lot billed to lilt ad the address identified above as the ACCOVArADDHEC{'for this site. I also certify[hal all <br /> infnrmalion provided on this application is true and correct and(hal all regulate(]activities will Ire performed in accordance pith all applicable SkN JOAQVIN COUNI V ORDINANCr-COMM and/or <br /> STANDARns and STATE,and/or FEDERAL Laws and ItEcVLi,I u).M. As the undersigned Olt-tier.Operator,./admrixd,lgrn/,lir ResPtrt+siAle Pa for the project located abovo under faciliti ile address•1 <br /> hereby authorize(he release of any and all results,reports,and other emiroanten(ol assessment information to SAN JOAQCIS COLN A" for <br /> III, II Dee AT as on as it is available <br /> and at(he sonic time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) Steve Valentine SIGNATU <br /> TITLE RP TAXIDN 555-94-096 <br /> APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE <br /> SITE MITIGATION AMOUNT PAID DATEOFYMENT PAYMENT TYPE RECEIPTS CHECK N RECEIVED BY WORK PLAN PE <br /> FEE:: <br />