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San Jd*in County Environmental Health Dament <br /> DATE QI./it MASTER FILE RECORD INFORMATION "MFRY' GREEIJFORM <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETETNEFOLLOW/NG PROPERTY OWNER INFORMATION.' CHECKlF OWNER CURRENTLYONF&EW1rH EHD <br /> PROPERTYOWNER NAME City of Lodi Dept of Public Works PHONE <br /> (209)333-6706 <br /> First M/ Last <br /> BUSINESS NAME Lodi Energy center SOC SEC rTAx ID# NA <br /> Owner Home Address DRIVER'S LICENSE# NA <br /> City STATE ZIP <br /> Owner Mailing Address 1331 South Ham Lane <br /> Mailing Address City Lodi State CA ZIP 95240 <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID# ACCOUNT ID# INV# <br /> CoMPLETETNEFoccoww BUSINESS/FACILITY/SITE INFoRMATloN: <br /> Is this a NEW Business,LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ No <br /> Is this an ExIS11No Business LOCATION but a New TYPE of regulated Business? YES ❑ No <br /> SusINESSIFACWTYISITENAME Lodi Energy Center <br /> SITE ADDRESS 12751 N.Thornton Rd SUITE BUSINESS PHONE <br /> CITY Lodi STATE CA ZIP 95242 <br /> BOARDOF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address IfDJFFEREArrhomFacN&Aaldreae Attention:or Care Of(opUoneq <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete ifBiII!ng Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESSNAME Stantec Consulting Corporation Attention:orCare Of(opdorsel) Gary Haeck <br /> Mailing Address 3017 Kilgore Rd. Suite 100 PHONE (916)861-0400 <br /> CITY Rancho Cordova STATE CA ZIP 95670 <br /> AccouNTADDREss for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: [,the undersigned Applicant,certify that I am the(boner,Operator,or Authorized Agent of this Business,and[acknowledge that aB PERMII'FEE4, <br /> PENALTIEY,ENFORCEMENTCHARC,ES and/or HOURf.Y CHARGES associated with this operation will be billed tome at the address identified above as the ACCOUNTADDREss for this site. I also certify 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 JOA UIN COUNTY Ordinance Codes and/or <br /> Standards and STATE andlor FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site dress,I hereby a a Ue the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVfItONMENTAL HEALTH DEPARTMENT as soon it is available an at 7e time it is <br /> provided to me or my representative. <br /> APPLICANT NAME Gary D. Haeck PLEASE PRINT SIGNAT <br /> TITLE DRIVER'S LICENSE# t y 7 <br /> Managing Senior Geologist PHOTOCOPYRE UIRED �J J <br /> C 7- <br /> Approved Sy Date Accounting Office Processing Completed By Date <br /> 29-02 1Oil2707 MASTER FiI,E.RECORD-GREEN <br />