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San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> SITE MITIGATION&LOP <br /> $NAMEDA&EAEF-0REHDQ$EONLY OWNER IDO CiA6E UNIT IV <br /> OWN ERMLE:COIMPLETETHE F01LOW/NG P RO PERTY OW N E R IA(FoRmA naw CH£CA'1F OWNER 0L/RREW7YYONf7tlEwTNEHD <br /> PROFEt7YOWNERNAhk (201937-8266 <br /> Fast Mf Lest PFIONE"DER <br /> BUMINEDe NAME e-mAIL ADDRF3s <br /> City of Stockton <br /> Owner Homs Addre" <br /> 425 N EI Dorado Street 2nd Floor _ <br /> city STATE T5202 <br /> Stockton C.4 <br /> Owner 1101a16V Address <br /> MaWbV Addrsaa CJly Sta1a Zip <br /> CORPORATION❑ INDfYIDUAL❑ PARTNUtSHIP❑ FEo Aoescr❑ On+ER❑ <br /> Stye NMQATION Emviw mmwTAL Attaraaatmc—VOW NTARY CLrANUP_WATER CAMU Y_HW P1P JHZ INvctr4ATMH LOP_ <br /> FACitJrviDO INvO AccOUNTID PR;eROOO AsalatEDE.MPLmEE LFJDAGENCf:EHO�WQCB D1SC_EPA, <br /> 6131 f '' <br /> FAGIuT1f Pitt! ComPILETE rNEFoLLowivG BUSINESS 1 FACILITY/SITE INFORMATtDAV <br /> Is this a NEW Business LOCATION notprovbusly regLiUded by the EWlRONmENTALHEALTH DEPARTMENT'? YES ❑ No <br /> Is this an EXISTING Buslr a LOCATION but a NEw TYPE of regulated Business? YES ❑ No <br /> BustNEsalFAtftmtSrrE NAME <br /> SITE AoDRzm O BU34NEssPHONE <br /> 1320 W Weber Ave. SurrF <br /> CRY STATE LP <br /> Stockton CA 95203 <br /> BtavQoFSUrERt/tsORDM1'Rlc'r U LOGTIONCODF ��( Keri KEY2 <br /> Ya11Yt{y <br /> Add mas A'D/FFE ENT IPI am FscA*Addrtrsa AffAndaw arCsre Of(opLfaW <br /> 425 N EI Dorado Street 2nd Floor <br /> Chy <br /> STATE TUP <br /> 202 <br /> Stockton CA 95 _ <br /> Ste CODE APHN <br /> �_ l I <br /> THIRD PARW BILLING INFO: Complete if Billing Party is different from Property Owner orPaciiity Operator identified above. <br /> BUSINFE8 NAVE ALbart6m:orCars Of(OP&r /J <br /> Cascade Drilling, L.P. <br /> Mailers®Address PHONC <br /> 3000 Duluth Street (916)638-1169 <br /> or" <br /> STATE ZIP <br /> West Sacramento CA 95691 <br /> d mQd�EOB for few and cbmngles OWNER FACILITYIBUSINESS X THIRD PARTY BILLING <br /> BIf.LING AND COJIPLIANCE ArK�vo_N'LED(,,%tENT: 1,the undersigned Applicant,certify that f am the Owner,Operator,or Aurhorked Agent of this Business,and I acknowledge that all PE)WIr FEES, <br /> PLMLTIeS,EAFORCE.IIEAT CH 4RCES nnd/or ffOLRLv CHARGES associated with this operation will be billed to me at the address identified above as the ACCO65vTADDRE55 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 appucabte SAN JOAQUIIY COUNTY Ordinance Codes and/or <br /> Staodards and STATE and/or FEDEttu.Laws and Regulations.As the undersigned owner,operator,or agent of the property located at the above facility/site address,i hereby authorize the release of <br /> any nod all results and en0coomental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTNIE, as soon as it a available and at the some time it is <br /> provided to me or my representative. <br /> APPLICANT HAME(PLEASEPRINT) Tabitha Taber-Cascade Drilling,L.P. BIONATt1RE Y <br /> TAX 10# <br /> TITLE Admin 27-0642404 <br /> Approved By Date Acoo Ofllce 0"ity Completed By Date <br /> 817E MITIGATION AMOUNTPAIo OA OF PAyf1ENT PAYMENT TYPE RecEIFfi C��l� RECEIVED BY WORK PLAN PE <br /> FEE:# BBs .... $��' t tF/Ll L <br />