Laserfiche WebLink
SAN J^ QUIN COUNTY ENVIRONMENTAL HEALT EPARTMENT <br /> DATE M�TER FILE RECORD INFORMATION ERT, GREEN FORM <br /> - SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHD USF ONU GWNERID# CASE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER ISCURRENTLYOHFREWITH EHD <br /> PROPERIYOWNERNAME Vance = I Anderson (209) 833-3400 <br /> FIRST MI LAST PHONENUMBER <br /> BUSINESS NAME ANDERSON ENTERPRISES LLC E-MAILADORESS <br /> vance I nxe nterp rises.com <br /> OWNER HOME ADDRESS RE 011an <br /> CITY STATE ZIP <br /> JAN 9 <br /> OWNER MAILINOADDRESS 724 E. GRANT LINE RD <br /> MAILING ADDRESS CITYTRACY BT^*� HEALTH <br /> CA ERM FR <br /> [RCORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP WATER QUALITY HW PIPELINE INVESTIGATION LOP <br /> -FACILITY ID INV# ACCOUNTID PIR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD"'RWQCB_DTSC_EPA_ <br /> JO HIVWN <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES DQ NO ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ NO CK <br /> BUSINESS/FAMUTY/SRE/PROJECTNAME ANDERSON PROPERTY <br /> SITE ADDRESS I PROJECT LOCATION 724 E. GRANT LINE RD SUITE# BUSINESS PHONE <br /> Cm TRACY STATE ZIP <br /> CA 95376 <br /> BOARD OF SUPERVISOR DISTRICT -Y LOCATION CODE 3 KEY1 KEY2 <br /> MAIUNG ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPRONAL) <br /> MAILING ADDRESS CITY STATE LP <br /> SIC CODE APN# CCMMEM: <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(OP)'IONAL) <br /> MAILINGADDRESS 837 SHAW ROAD PHONE 209-467-1006 <br /> CITY STOCKTON STATE CA zip 95215 <br /> ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNER❑ FACILITYIBUSINESS❑ THIRD PARTY BILLING[] <br /> BILLING AND COMPLIANCE.ACKNOWLEDGMENT: 1,the undersigned Applicant,cerfify that 1 am the Owner,Operator,Authorized Agent,or Responsible Parry and I acknowledge that all PERMITFE£e, <br /> PENALTIES,ENFORCEMENT CHARLEY and/or HDURLYCHARGES associated with this project will be billed to me at the address identified above as the AGCY)UNTADoR 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 Owner,Operator,AutborileAAgent,or Responsible Party for the project located above under facility/site address,I <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQIRN COUNTY ENV RONAIENTA,HEALTR DEPAKTb Yf as Soon as it is available <br /> and at the same fine it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) TIM CUELLAR SIGNATURE ' \ <br /> TITLE PROJECT MANAGER TAXID# <br /> APPROVED BY DATE AC....TIN.OFFICE PR..EBBING COMPLETED BY DATE <br /> S ITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY W �P�E <br /> FE:E <br />