Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE I]iS.113 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADED AREAS FOR EHD USE OHLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CNECK/FOWNERI9 CURRENT[YON FILE WITH EHD <br /> PROPERTY OWNER NAME 1 <br /> FIRST Ail L-4ST `PHONE NUMBER <br /> BUSINE99 NAME Pacific Gas&Elcc(Hc E-MAILADDRESS <br /> OWNER HOME ADDRESS 3401 Crow Canyon Road <br /> CITY San Ramon STATE ZIP <br /> CA 94553 <br /> OWNER MAIDNG ADDRESS <br /> (same a,above)c.'o Sharon L.Reackhof <br /> MAILING ADDRESS CITY STATE ZIP <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID INV# ACCOUNTID PRWRO# ASSIGNED EMPLOY; LEAD AGENCY:EHD RWQCB_DTSC_EPA_ <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED DY TI IE ENVIRONMENTAL HEALTI I DEPARTMC-NT? YES ❑ No EI <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No II <br /> BUSINE99/FACIUTYISITEIPROJECTNAME \1ae911t Lot <br /> SITE ADDRESS I PROJECT LOCATION 712 South Sacramento Street SUITE# BUSINESS PHONE <br /> CITY Lodi ZIP <br /> Lotti <br /> CA 6S240 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEYZ <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> Terra Pacific Group Rick McCartney <br /> MAILING ADDRESS CITY STATE LP <br /> 201 Nonh Civic Dri%c,Suite 135,\dial Crcck CA 94596 <br /> SIC CODE <br /> N# COMMENT: <br /> 045-32-600 11 <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME'1"erra Pacific Group ATTENTION:ORCARE OF(OPTIONAL) <br /> Rick McCarine <br /> MAILING ADDRESS 201 Noah Civic Drive,Suite 135 PHONE <br /> 925-951-6000021 <br /> CITY Walnut Crcck STALA9 <br /> TE 14596 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTYBILLING0 <br /> DaLISG AND CONIPLIASCE ACKNO%YLEDGVENT: 1,the undersigned Applicant,cerrify-that I am the(brner,Operator,AirthorizedAgem,or Relpun%ible Parr and I aclawnledge that all PERVIT FEES, <br /> PExrawC,FNFORCEIIEAT Of.LRGES and/or 11OURLYOLIRGES associated s%ith this project sill be billed tonic at the address identified above as the Aa 01'.NT.InnRESS for this site. I also ccrlih'(hat all <br /> information provided on this application is true and correct;and that all regulated activities%sill be perforated in accordance Isiih all applicable SAN JOAQLIN COLNTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDER\L La)%s and REGEL{TIONA As the undersigned Owner,Operator,Audmri,ed Agent,or Rnpnrnihle Rvfy for the project IDC:lted above under fa dih'/site address,I <br /> hereby mHhorim the release of:In%and all results,reports,and other en%ironmenial nssessment information to SAN JOAQULN COL:NTY ENviRLIN%IENJAL HEALTH DEPART>rENff,"(S D as It is available <br /> and at the same time it is provided to me or my representative. / I <br /> APPLICANT NAME(PLEASE PRINT) /-'L�JSIGNATURE //�� <___�✓ <br /> t <br /> TITLE / 'I , TAX ID# <br /> APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# JRECEIVE08Y� <br /> WORK PLAN PE <br /> FEE: <br />