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San Jo-jin County Environmental Health Ceirtment <br /> RM <br /> DATE oz/o9/2012 MASTER FILE RECORD INFORMAnON"MFR" GREENwN <br /> SITE MITIGATION8 LOP <br /> ;g�rED.AIW,WFoa LH ods Y OWIEot IiDAA#6RL0 fo13S- I UNIT IV <br /> FIM:COMPLETE THEfOLLON7NG PROPERTY MNER kmoilixtiTiaw EF,OWNER CuawExnrovsne Nutt I�c <br /> PROPERTY OWNER NAPE Robert Kupka <br /> Rst An Las PHONENMW <br /> E LADORFBE <br /> BUSOMS Lodi Airport Corporation <br /> owner Hp Address <br /> CRY STATE LP <br /> oWrtsr Meanp Addraas PO Box 10 <br /> StatAaar+eacaye CA rap 95220 <br /> Acampo <br /> CARPORATtdI❑ IxONIWAL❑ Fl R NERSHm❑ FED AcexcY❑ orri0 <br /> Srte MMOATION_ENVIRONMENTAL ASSEMMoa_VOLUNrARY CLEANUP—\R.WATER QUALITY_14W PIgPEUNB INVEMQATION_LOP XX <br /> FACiLnY ID# INV# Accedm lD PRNRO# . .. _e g , u,y� N ,. <br /> FACRJTYFILE COAFPLETE THEFOLLowIN>i BUSINESS I FACILITY I SITE INFORMA TION.• <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No U <br /> Is this an Exl$TIMG Business LOCATION but a NEW TYPE of regulated Business? YES, ❑ No <br /> BttmNESSIFACILRYMS NAME Lodi Airport <br /> SITE AOORE39 SURE# BUSINESS PHONE <br /> 23987 North Highway 99 <br /> CRY Acampo <br /> STATE CAZIP 95220 <br /> BOMDOF 911PERVIeOR OMfRICf LOCATION COOS KEH KEv2 <br /> Mailing Address ifDIFFEREN how,FactilifyAddreaa Attention:aCara Of(opdoM) <br /> Mailing Address City 7� STATE TIP <br /> SIO CODE APN# C,& !5 <br /> L 5 /70 d 7 COIaENr: <br /> THIRD PARTY BILLING INFO: Complete ff Billing Party is different from Property Owner or Facility Operator identifiedabove. <br /> BUSINESS NAME Advanced GeoEnvironmental Attention:orcareof (ophiPneli W Little <br /> Mailing Address 837 Shaw Road PHONE 209 467 1006 <br /> STATE zw 95215 <br /> C" Stockton CA <br /> &gggMMAffl=for fees and charges OWNER FACILT'/BUSINESS THIRD PARTY BILLING <br /> E,ILL,,,A,,,CON,,I,,,,,Ac,NowLjnI f,Me mtdmigmd AppBonC certify out f am the Owen,Openmr,"AUthniUd ATenr of l b Btaineas,ad I aeknewledge that dl PE.rMIT FRFs, <br /> PENN../PS,ENrO.tC WW CXAa u atN/or HMMLYCMA Gf MMIted with this operation will be bided to ON at the address identified above as the Ac^_xrw 1ppjjg=for ON site. i abo certi%that all <br /> information provided on this appikation N into and enmesh std that all regulated activities will be performed In arceni with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STAT[And/or F EDERAt.Laws and RegWatiom. As the mdendptM owner,operator,or agent of the property located at the above helBrynNe addros,I hereby Ruth.rim,the ukase of <br /> any and all mWb and environmental nsetarnent information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as saw u it Y avaBabk and at the same time tit is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) William Little SICHATURE <br /> TITLE Geologist TAxID# 68-0354606 / <br /> APprewd By Dade Acoountlwq Ofnew Prnea"2g Completed By Debt <br /> $ITEMITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPTS CHECK# RECEIVED BY WORN PLAJI <br /> FEE:f <br />