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SAN J0?f4UIN COUNTY ENVIRONMENTAL HEALTH DbroAh,MENT <br /> DATE02/22/13 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> " 1�• ��s OWNER IDs CASE. S-R oo 46 723 UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: ONECRYPOIEMBT NCUMRENnYONP/LENYT//END <br /> PROPS OWNENNAME ) (209) 937-8349 <br /> RBST I MI LAST PHONENUMBER <br /> BUSINESS NAME City Of Stockton E ILADORESS <br /> reid.ca m pbe I I@stocktongov.co <br /> OMERHOMEADDRESI 345 North Eldorado Street <br /> CITY Stockton STATE CA 7" 95205 <br /> ONNERMUUNOADDRE 2211 N Wilson Way <br /> MatRO ADDRESS Cm Stockton STATE CA a' 95205 <br /> 11CORPOMYI011 ElINDNIDUAL ElPARTNERSHIP INq GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OSIER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION__LOP xx- <br /> FACILT'IDA IHV# ADDODNT ID PR 01 ASSIGNED EMPLOYEE LEAD AGENCY:EHO RWQCB_DTSC_EPA_ <br /> 39352 !94 ��s`i <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY TH E ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES KI NO ❑ <br /> BUSINESS/FAciI /SITEMRWI NAIAE Larrys Auto - Charles Skobrak Property <br /> SfTEADDRESSIPROJEGTLOCATIIRt 308 North Grant Street SUITE# BUSINESS PHONE <br /> 209-467-1006 <br /> Cm Stockton STATE 'P 95205 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE Merl KEY2 <br /> MAILIND ADDRESS,IF DIFFERENT FROM FACIE"ADDRESS ATTENTION:ORCARE OF?Op710NALJ <br /> MAIUNG ADDRESS CITY STATE Zip <br /> SIC CODE APNA-nOYLGW COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME Advanced GeoEnvironmental Inc. ATTENTION:ORCAREOF?OPTAOAML.)William Little <br /> MAIuNCADDRESS 837 Shaw Road PHONE 209 467 1006 <br /> Cm Stockton STATE CA Z'P 95215 <br /> ACCOUNTADORESSTo SENDFEESANOCHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING <br /> BILLING AND COMPLIANCR ACKNOW LFUGMe1NT: I,the undersigned Applicant,certify that I am the Thune,,(Jperutrv,An@Pr$ed Ab ny m RespwMible Parry and I acknowledge that all PERMITF£Ec, <br /> PENALTIES,ENFOR(EMENI'CHAHGE.S and/or HouRLYCHAR(/ES associated with this project will be billed to me at the address identified above as the ACCOHNT'ADDEeSS for this site. 1 also certify that all <br /> information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Ows,,,Opernlot,Autlmrized Agent,or Responsible Party for NN project located above udder facility/Site address,I <br /> hereby authorize the release of any and all resulh,reporh,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available <br /> and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) William Little SloruTDlle (/�' 1 aL.,k.. - <br /> TITLE Geologist TAXIDA <br /> APPROVED BY DATE ACCOUNONGO CEPROCESMNGCOMPIl BY SITE r 1� <br /> SITE MITIGATION AMOUNTPAID DATE OF PAYMENT PAYMENT TYPE RECEIPT CHECK# RECEIVED BY WORN PUN PE <br /> FEE:; -OJ/—o/ <br />