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SAN RUIN COUNTY ENVIRONMENTAL HEALTH OARTMENT <br /> DATE ! 1MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> SITE MITIGATION& LOP <br /> GRADED AREAS FOR END USE ONLY OWNER ION CASE If UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECKWONWERASCURRENTLY OHF/LEWITH EHD ❑ <br /> PROPERTYOWNERNAME Mila Padilla <br /> FIRST MI LAST PHONE NUMBER <br /> BUSINESS NAME /J EMAIL ADDRESS <br /> L(✓✓P <br /> OWNER NOME ADDRESS <br /> Cm STATE LP <br /> OWNER MAILING ADDRESS P.O. <br /> BOX 1036 <br /> MAILING ADDRESS CITY Tracy STATE 95378 <br /> CA <br /> ❑CORPORATION ®INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP WATER QUALITY HW PIPELINE INVESTIGATION LOP <br /> FACILITY ID# NvAl7j ACCOUNT ID PR#IRO# ASeIGNEO EMPLOYEE LEAD AGENCY:EHD, C�-RWOCB_DTSC_EPA <br /> Joalvu y <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BYTHE ENVIRONMENTAL HEALTH DEPARTMENT? YES ® No ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ NO 29 <br /> BUSINESS/FAC1LmI8ITEIPROJECT NAME Proposed 7-11 #36084 <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 V J KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS `J ATTENTION:ORCARE OF(OPr/ONAL) <br /> P.O. Box 711 <br /> MAILING ADDRESS cm Dallas TX STATE L°95221 <br /> SIC CODE APN# COMMENT: <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 O�(CmrMMAL) <br /> L G <br /> MAILING ADDRESS 3017 Kilgore Road, Suite 100, Rancho Cordova, CA 95670 PHONE 916-384-0706 <br /> cm Rancho Cordova STATE <br /> A 'P95670 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING® <br /> BILLING AND COMPLIANLT Acaiow FuGmFw: I,the undersigned Applicant,certify that I not the Omer,Operator,AWhorgedAgesd,or Resp°milde Party and I acknowledge that all PERADT FEES, <br /> PEmiYzEs,EATYIRCEMEATCiz utGEs av&or HOURLY CHARGES associated with this project will be billed tome at the address identified abore as the A xoO ADDRHSS for this site 1 also certify that all <br /> information provided on this appliestion is true and correct;and that aU regulated activities will be performed in accordance with all applirabll SAN JOAQUIN COUNTY ORDINANC CODES Sadler <br /> STANDARDS And STATE and/or FEDERAL Laws and REGULATIONS. As the mdersigned Owmn,Opnoror,AuMar¢edARenL or RsparoiMe Party fn the project looted above order fautity/aiM address,I <br /> hereby authorize the release of any and all remits,reports,and other environmental assessment information to SAN JOAQUINENVIXON otEn L HEALTH DEPARTAA:MT AS Soon AS it a available <br /> and et the same time it is provided to me or my representative.APPLICANT <br /> 1 <br /> APPLICANT NAME(PIEASE PRINT)Danielle Manning SIGNATURE <br /> TITLE Project Manager TAKID# <br /> APPROVED By I DATE ACDOU"IING OFFICE PROCESSING COMPLETED BY DATE <br /> S ITE MIITTTNMTION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY Wow PLAN PE <br /> FEE:; C 25- -<W <br /> JJJ <br />