Laserfiche WebLink
SAN I&QUIN COUNTY ENVIRONMENTAL HEAL'I,EPARTMENT <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> I•�U'/� SITE MITIGATION & LOP <br /> SHADEDAR 3FQRFHDUSFONIY OWNER ID#dkko.-4 S96 CASE# S,\(//Y�W7/381 UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE 1PARTY INFORMATION: CHECK IF OWNER IS CURRENTLrON FILE WTHEHD El <br /> PROPERTY OWNER NAME Vance Anderson (2o9) 833-3400 <br /> FIRST MI LAST PHONE NUMBER <br /> BUSINESS NAME ANDERSON ENTERPRISES LLC €-MULADORESa <br /> vance I nxenter rises.com <br /> OWNER HOME ADDRESS R ex <br /> Cm STATE kip <br /> OWNER MAILINGADDRESS 724 E. GRANT LINE RD <br /> MuuNopaDRESSCITY TRACY STATE NY CA E H <br /> [XCORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITYID# INV# ACCOUNT IC PR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD1` RWQCB_DTSC_EPA_ <br /> 15ACDA7-7/,.7 A� o4l72D �x,Q,y39jr� .Io NNIV y <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES VY NO ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No <br /> BUSINESS/FACIUTY/SITFJPROIECTNAME ANDERSON PROPERTY <br /> SITE ADDRESS/PROIECT LOCATION 724 E. GRANT LINE RD SUITE# BUSINESS PHONE <br /> CITY TRACY <br /> STATE ZIP <br /> CA <br /> BOARD <br /> 9S <br /> BOARD OF SUPERVISOR DISTRICT LOCATIONCODE 3 KEY1 KEYZ <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:OR CARE OF(OPTIONAL) <br /> MAILINGADDRESSCITY STATE ZIP <br /> SIC CODE APN# COMMENC <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:ORCARE OF/OPIRWALJ <br /> MAILINOADDRESS 837 SHAW ROAD PHONE 209-467-1006 <br /> CITY STOCKTON STATE CA ZIP 95215 <br /> ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING[] <br /> BU.LING AND COMPLIANCE ACKNONLEIx;M1IENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,Audmrized Agent,or Responsible Party and 1 acknowledge that all PERMIT FEES, <br /> PENALTTEY,ENFORCEMEWCRA m and/or HOURLY CH GEV associated with this project will be billed to me at the address identified above as the ACCOUWAntntem for this site. I 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 COUYIY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL Laws and REa11 nONS. As the undersigned Owner,Operator,Authorized Agent,or Responsible Party for the project located above under facility/site address,I <br /> hereby he same t the releaseofany and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTYTro <br /> NM1IENI'AL HEALTH D soon as it is available <br /> and at Me same time it is provided to me or my representative.APPLIcANTNAME(PLEASEPRINTI TIM CUELLAR SIGNATURETITLEPROJECT MANAGER TABID# �p- <br /> APPROVED BY DATE ACCOUNTNO OFFICE PROCESSING COMPLETED BY DATE <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMEM PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PI�AN—PTE <br /> FEES 390 340 /•�•/7 e el< //05-3 COCtUTE /`�'✓` ) <br />