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i San Jr. .Aluin County Environmental Health Dot. � rtment <br /> DATE 05/09 /12 MASTER FILE RECORD INFORMATION NFRH GREENFORM <br /> 1y SITE MITIGATION & LOP <br /> SHADEDAREAS FOR END USE ONLY OWNER ID# CASE # �D nor L( q oy UNIT IV <br /> OWNER FILE : COMPLETE THEFOLLOW/NG PROPERTY OWNER /NFORMAT/ow CI ND�K/F OWNER CURReynyONF"Winf EHD <br /> PROPERTYOWNERNAME Dave Gaurdino /2 /09 ` 466- 9678 <br /> First MI Last `PHONENUMBER <br /> BUSINESS NAME E ut.Ammmss <br /> Gaurdino G Crawford Construction N/A <br /> Owner Home Address <br /> 9833 South Sack Tone Road <br /> City STATE 21P <br /> Stockton CA 95215 <br /> Owner Mailing Address <br /> 517 West Fremont Street <br /> Melling Address City State Zip <br /> Stockton CA 95203 <br /> CORPORATION [I INDIVIDUAL ® PARTNERSHIP ❑ FED AGENCY ❑ OTHER ❑ <br /> SITE MITWATON _ ENVIRONMENTAL AssESSMENT _ VOLUNTARY CLEANUP _ WATERQUALrrY _ HWPIPELINElitive IGATION _ LOP <br /> FACIUTYID # INV# AOCOUNTID PR RO# ASSIGNEDEMPLOYEE LEAOAGENCY: EHD RWQCB_ DTSC _ EPA _ <br /> 99 ? moo / #tr <br /> FACILITYFILE COMPLETE TNEFOLLOW/NG BUSINESS / FACILITY / SITE /NFORMA r/ON: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No El <br /> Is this an EXISTING Business LOCATION buta NEINTYPE of regulated Business? YES ❑ No El <br /> BUSINESS/FAcJUTY1SITENAME Guardian & Crawford <br /> SITEAamams SUITE# BUSINESSPHONE <br /> 517 West Fremont Street 209 -466 -9678 <br /> CRY STATE ZIP <br /> Stockton CA 95203 - <br /> BOAROOFSUPERVISORDisrmoT LOCAHONCODE KEY/ KEY2 <br /> Mailing Address YDIFFERENrdTNn FaclihipAoSYrese Attention: orCare Of (ophlona9 <br /> Mailing Address City STATE 21P <br /> SICCODEAPN# COMMENT: <br /> / 37 - ziL/- ia <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identifiedabove. <br /> BD$INE d nA� RoOpton <br /> Advanced GeoEnvixonmental Inc . Attention: <br /> Melling Address PHONE <br /> 837 Shaw Road 209 - 467 - 1006 <br /> CITY STATE ZIP <br /> Stockton CA 95215 <br /> AccauATAnaasw forfees and charges OWNER FACILITY/BUSINESS THIR&MMBILLING <br /> BMLLNG AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that 1 am the Owner, Operator, or Authorized Agent of this Business, and I acknowledge that all PERAID FEES, <br /> PENALTIES, ENPORCEMEWCnARG£.0 and/or RDDRLYC1&iRGES associated with this operation win be baled tome at the address identified above as the AccouNT'Abumss for this site. 1 also certiry 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 JOAQUW 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 located at the above facility/site address, I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR MINT ait is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME (PLEASE PRINT) Robert Marty SIGNATURE <br /> TITLE President TAX ID # <br /> N/A <br /> Approved By Dab Accounting Mee Processing Completed 9y Data <br /> SITE MITIGATION AMOUNT PAID DATEOFPAYMENT PAYMENT TYPE RECEIPT# CHECK # RECEIVED BY WORK PLAN PE <br /> FEE: $ co ) <br />