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0 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> 4/31 SITE MITIGATION & LOP <br /> SHADED AREAS FOR END USE ONLY OWNER ID# / �j O 47 CASE# SRv06-2 O 1 Y UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK x O"ER is CuRRENTL I,oN me wITH EH DO <br /> PROPERTYOWNERNAME Mila Padilla ( ) <br /> FIRST MI LAST PHONE NUMBER <br /> BUSINESS NAME �' EMAIL ADDRESS <br /> L(✓✓C -�' U f {' �lA rl N� <br /> OWNER HOME ADDRESS <br /> CRY STATE LP <br /> OWNER MAILINGADDRESSP O. BOX 1036 <br /> MAILING ADDRESS CITY Tracy STATE 'P95378 <br /> CA <br /> ❑CORPORATION ®INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PAM ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP_WATER QUALITY_FIW PIPELINE INVESTIGATION_LOP_ <br /> FACIun ID INV# ACCOUNT ID PR RO# ASSIGNED EMPLOYEE LEAD AGENcv:EHDLRWOCB_DTSC_EPA <br /> ;-173 9' 3 f q- 537?v� JoHuu y <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS TH IS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ® NO ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES ❑ No 91 <br /> BUSINESSIFACILITYISRE(PROJECT NAME Proposed 7-11 #36064 <br /> SITE ADDRESS I PROJECT LOCATION SUITE# BUSINESS PHONE <br /> 620 Eleventh Street <br /> Cm Tracy CA STATE ZIP <br /> 95376 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE J KEPT KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS `J ATTENTION:ORCARE OF(OPPONAL) <br /> P.O. Box 711 <br /> MAILING ADDRESS c"Dallas TX STATE ZIP 95221 <br /> SICCODE APN# D r DD-7 oOMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME Stantec Consulting Services Inc. ATTENTION:ORCARE 0E-)177V/ <br /> -)17 xayL IL <br /> 2 <br /> MAILING ADDRESS 3017 Kilgore Road, Suite 100, Rancho Cordova, CA 95670 E 916-384-0706 <br /> CRY Rancho Cordova CA "°95670 <br /> ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING® <br /> RWuNO AND COasl.lANt ACKNowtxro;wNT: 1,the undersigned Applicant,certify,that I am the Omw,Operator,AuthorgedAgm4 or Rspomibk Pmfy end I aelmowledge,that all Pluest rflou, <br /> PPNALrmT,Eaa'oRCEntmTCrugDPs mdlor HODRLYCRAR associated with this project will be billed Is mat the address identified above as the ACCOnM'ADDRasS for thio site. I deo certify that all <br /> iuformatoes provided on this application is true sed earrech and that all regulated activities will be performed in aceordarvee with all applicable SAN JOAQM CoIIMIY OaDDUNCE CODES and/or <br /> RrANDAROs and STATE aed/or F'EDERAL Lars and REGULATIONS. As the undersigned Owns,Operator,AuthoriiedAgeT4 orRsponsible Petry fm the project derated above ruder faoliy/site add.,I <br /> hereby authorize the release of any sand W results,reports,Sued other environmental sesmament information to SAN JOAQUIN ENVmONS EHY&L 119"TH DEPAarsiEHT a,soon as it is available <br /> and at the acme time it is provided to me or my represehtive. <br /> APPLICANT NAME(PLEASEPRINT)Danielle Manning <br /> TITLE Project Manager TAXID# <br /> APPIIOVED BY DATE ACCOUNTINGOFTICEPROCESSINGCOMPLETEUBY DATE <br /> SITE MITIGATIIOO"N AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECCCK-��y�.# RECEIVED BY WORK PUN PE <br /> FEE:$37 13-7� �b I� � J 1 9/-- <br /> ---_ "J-�� <br />