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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE 1� MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> SITE MITIGATION$LOP <br /> SHADED AR SFOR EHO USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECKIFOWNERISCURRENTLYa FneRYrn EHD � <br /> PROPERTY OWNER NAME Daniel W Munzer 562)283-1014 <br /> FIRS, MI LAST PHONE NUNRER <br /> BUSINESS NAME MUnco,Inc. EMARADDRESS <br /> dmunzer@muncol.com <br /> OWNER HOME ADDRESS <br /> 3450 E.Spring Street,Suite 218 <br /> On Long Beach STATE ZIP <br /> CA 90806 <br /> OWNER MAILING ADDRESS 3450 E.Spring Street,Suite 218 Z� <br /> MAILING ADDRESS CITY Long Beach STA 6A 9"0806 <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ®RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER DUALITY_HW PIPELINE INVESTIGATION—LOP <br /> FACILITYID# INV# ACCOUNTIO 4!rjkRO# ASSIGNED EMPLOYEE LEAD Anil EHD_RWQCB>(-DTSC_EPA_ <br /> 6420-f o JoFIMRay <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS ANEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARfMENTT Yes ❑ NO <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No <br /> BUSINESS(FACIDTYISrrFJPROJECTNAME Koppel Stockton Terminal <br /> SITE ADDRESS(PROJECT LOCATION 2025 West Hazelton SUITE# BUSINESS PHONE <br /> CITY Stockton STACA 95203 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE / KEYi KEY2 <br /> MAILINGADDRESS,IF DIFFERENTFRoss FACILITY ADOeass ATTENTION:ORCARE OF(OPTIONAL.) <br /> 8067 East U Ave. Abe Northup <br /> MAIuNGAODRESSCITY Vicksburg SO' <br /> 49097 <br /> SIC CODE APN# Ild5 _02c-) r-) <br /> COMMENT:COMMENT: <br /> 11 <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME CH2M HILL ATrENT1011:ORCARE OF(OPTIONAL) <br /> Abe Northup <br /> MAILINGADDRESS 6067 East U Ave. PHONE 269-358-2165 <br /> CITY Vicksburg STATE ZIP <br /> MI 49097 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNERE] FACILTTYIBUSINESSO THIRD PARTY BILLING® <br /> BILLING INC AND Com• t Wn:\CBKO\YI,FOcniRNT: 1,IIIc undersigmd Applicant certify that(Con the Owner,OPcmbrr,dnlhorc oI Aga M,m Responsible Porto and 1 aelmaYledgc that allPERdHr FEES, <br /> PI=e.AI.TIY.Y}Gn'FbRCF.'AIfLM1T CH;IRNEC and/m HOFRLYCHIRGET all(ndated pith this project\till be biped towel,(be a k res,Identified above as the ACCOE9'TArwituMY for this Site. I also certify Net a1I <br /> information provided on this apppealioo is true and Correct;and that all r palated acfiaitivo mill be porfnrmid in accordance pith an applicable SAN JOAQUIN COUK,Y ORDIXANCE CODES an vOr <br /> $fdNKIIIDS and Sfcrr,anlfor FRiSfAm.Lmrs and RE(:ULnY'IONS.:\s the orders-good 0wner,0"mr,"Ambariaed Agenq nr Resp otab/e Fart•for the project looted above under facility/sho address,I <br /> Imreby anfharia:Cho rek:¢e of any and aR results,repurL%and ethef em ironmemil assossment information to 9\.v JOAQUIN Coutt' IAeYRONNBIA,.1 HE"Uni DEe.uiTnlENn7 as soon as iC is available <br /> and a(the cone time it u provided m me or my rtpres'entatNe. If// 1`IJ/t11L/1/1�Q nl <br /> Al NAME(PLEASE PRINT) Abe Northup SIGNATURE <br /> Tine Project Manager TAx ID# 32-0100027 <br /> APPROVED BY DATE ACCOUNTING OFFICE PROCESSMS COW"YED 6Y DATE <br /> SnE MITIG/d°gy AMOUNT PAID DATEOFPAYMENT PAYMENTTYPE RECEIPT# CNECK# RECEIVED BY WORNvPLAN PE <br /> FEE:S _ I / <br />