Laserfiche WebLink
SanJ ( , uin County Environmental Health L'e ar me- nt - — <br /> DATE 11 - 04 - 2011 MASTER FILE RECORD INFORMATION "MFR*OV 2 2011GREEN FORM <br /> ATION & LOP <br /> SHADED AREASFOR END USE ONLY OWNERID# CASE #S�jpp` att PEflMIY SEfl111C 1wIT IV <br /> OWNER FILE : COMPLETE THEFOLLOW/NG PROPERTY OWNER /NFORMAT/ONw CIAWKIF OWNER CURRENMYONFiLEW?H END <br /> PROPERTY OWNER NAME ( ) 209 - 466 - 3554 <br /> First Ml Last PHONENum&R <br /> BUSINEsS NAME E, MILADDRESS <br /> E1 Dorado Land LLC NA <br /> Owner Hanot Address <br /> P . O . Box 6036 <br /> City LATE zip <br /> Stockton CA 95206 95206 <br /> Owner Mailing Address <br /> Same as Above <br /> Mailing Address City Stain zip <br /> CORPORATION INONIOUAL❑ PARTNERSHIP ❑ FEDAGENCY ❑ OTHER ❑ <br /> SITE MITIGATION _ ENVIRONMENTAL ASSESSMENT _ VOLUNTARY CLEANUP — WATER QUALITY_ HW PIPELINE INVESTIgATON _ LOP x <br /> FACILITYID# INV# ACCOUNT ID PR RO # ASSIGNED EMPLOYEE LEAD AGENCY: EHD--- RWOOB _ DTSC_ EPA_ <br /> 3 r Ro * Sao / 459 <br /> FACILITYFILE COMPLETE THEFOLLOW/NG BUSINESS / FACILITY / SITE /NFORMAT/ON.' <br /> Is this a NEW Business LOCATION.notpreviously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No 0 <br /> Is this an EXISTING Business LOCATION luta NEW TYPE Of regulated Business? YEs ❑ No <br /> BUSINESSIFACIUTY/SRENAME pacific Pride - South El Dorado Street <br /> SITEMORESS SUITE# BUSINESSPHONE <br /> 3147 South E1 Dorado 1 - 209 - 466 - 3554 <br /> CITY STATE zIP <br /> Stockton CA 95206 <br /> BOARD OF SUPERVISOR DISTRICT LOCATIONCODE KEY1 KEY2 <br /> Mailing Address HD/FFERENTfromFaa//HyAddrase AUention: orOare Of ppff tp <br /> Melling Address CKy STATE zip <br /> SICCCOE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner oFFacility Operator identifiedabove. <br /> BUSINESSNAME Advanced GeoEnvironmental Inc . Attentlon: orcareOf (opacnaV Tim Cuellar <br /> Mailing Address 837 Shaw Road PHONE I - 209 - 467 - 1006 <br /> Cin STATE LP <br /> Stockton CA 95215 <br /> AWOYAfT.AWREW furfees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 15 the undersigned Applicant, certify that lam the Owner, Operator, or Authork d Agent of this Business, and I aehnmvledge that all PERJUITFEES, <br /> PENALTIES,ENFORGEUENICRARGEB and/or HOVRI.YCKARCEc associated with this operation will be billed tome at the address identified above as the ALrOmrvrADDRESSPor this sib. 1 also eerNfy that <br /> all 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 Ordinance Codes and/or <br /> Standar Its and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner, operator, or agent of the property located at the above facility/site address, l hereby authorize file release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP 1ENT as son as it is available anJ at the some time it is <br /> provided to me or my representative. <br /> APPLICANT NAME (PLEASE PRINT) Robert Marty SIGNATURE <br /> TITLE president TAX ID # tJ <br /> Approved ay Date Accounting Office Processing Completed By Date -/ <br /> SITE MITIGATION AMOUNTPAID DATEOFPAYMENT PAYMENTTYPE RECEIPT# CHECK # RECEIVED BY WORK PIAN PE <br /> FEE: <br />