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SaLn '�64_,Wn County Environmental Hes�th D-*_ _ <br /> DkT,E I 4.3 .- c.F P GREEN FGRI"IG <br /> � MASTER EBBE RECORD �NFORIwATIC)I� �� <br /> SHADED AREAS FDR EHD USE ONLY OWNER ID# CASE# UNIT F <br /> '!f <br /> OWNER FILE <br /> COMPLETErNEFOLLOW/NGPROPERTY OWNER INFORAIAriow CHEcKIF0WNEROURRExriroAfjr&wtrHEHE. <br /> PROPERTY OWNER NAME City of Lodi Dept of Public Works PHONE (209)333-6706 <br /> First Mt Last <br /> BUSINESS NAME Lodi Energy center SOO SEC iTAx ID <br /> NA <br /> Owne r Home Address DP.IVER'ELicENSE# NA <br /> City STATE zip <br /> Owner Mailing Address 1331 South Ham Lane <br /> Mailing Address City Lodistate CA zip 98240 f <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FFO AGENCY❑ OTHER <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID b' ACCOUNT ID# ' <br /> INV# <br /> i <br /> COMPLETE MEFOLLOwlAfG BUSINESS I FACILITY I SITE INFORMATION; <br /> IS this a NEW BusineSS'LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ No <br /> Is this an Ex*TING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINEssIFACILITYI&TE NAME Lodi Energy Center <br /> SITE ADDRESS 12751 N. Thornton Rd SUITE# BuSINESSPHONE <br /> CITY Lodi STATE CA ZIP 95242 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION COnE - KEY1 KEY2 <br /> Mailing Address IfDIFFERENTfrom FacllltyAddress Attention:or Care Of(optional} <br /> Mailing Address City STATE zip <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of (optional} <br /> Stantec Consulting Corporation Gary Haeck <br /> Mailing Address 3017 Kilgore Rd, Suite 100 PHONE <br /> (916) 861-0400 <br /> CITY Rancho Cordova STATE CA zip 95670 <br /> ACCOUAlrADORESs for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT,FEES, <br /> PENAL77ES,ENFORCEMENT CHARC&T and/or HOURLY CHARC$S associated with this operation w9!be billed to me at the address identified above as the A CCOUR'TALbRE,S$for this silt. I also certify that <br /> all information provided on this application is true and correct,and that all regulated activities will be performed in accord:=. <br /> le SAN JOA UIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property ility/site " dress,I hereby a Brite IIIe release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALsoon it is available an avihe same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME Gary D. Haeck PLEASE PRINT SIGNAT / � <br /> TITLE DRIVER'SLICENSE# ` �r( � s <br /> Managing Senior Geologist PHOTOCOPY REQUIRED 7 �y <br /> Approved 8y Date Accounting Oftice Processing Completed t3y Date <br /> 29-D2 10/12/07 MgSTER FILE RECORD-GREEN <br />