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� M <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> _ SITE MITIGATION & LOP <br /> a"A9110 AtecAtt FOR EHD USE ONLY OWNER ID# CASE#� UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IFOWNER IS CURRERTITONFILE WITH EHD <br /> PROPERTY OWNER NAME Daniel W Munzer 562)283-1014 <br /> FIRST MI USr PRONENumsest <br /> BUSINESS NAME MunCo,Inc. E-lAAlimunzer@muncol.coln <br /> OWNERHOMEADDRESB <br /> 3450 E.Spring Street,Suite 218 <br /> Cm Long Beach STATE 7P <br /> CA 90806 <br /> OWNERMAH-NGAOORERS 3450 E.Spring Street,Suite 218 <br /> MAILING ADDRESS CRY Long Beach STAjE LPO6O6 <br /> ❑CORPORATION Ll INDIVIDUAL El PARTNERSHIP ❑GOVERNMENT AGENCY IN RESPONSIBLE PARTY 9 ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT_,-VOLUNTARY CLEANUP_WATER QUALITY HW PIPELINE INVESTIGATION LOP <br /> FACILITY ID# INV# ACOOUNTID PR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB DTSC_EPA_ <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL IIEALTN DEPARTMENT? VES ❑ NO <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? Yes ❑ No <br /> BUSINESS/FACILITYISITEIPROJECTNAME Koppel Stockton Terminal <br /> SITEADDRESS/PRWECTLOCATION 2025 West Hazelton SUITE# BUSINESS PHONE <br /> CITY Stockton STAzip <br /> CSA95203 <br /> BOARD OF SUPERVISOR DISTRICT ( LOCATION COO-777E7 <br /> OO- / KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTEN-now ORCARE OF(0PTI0RAL,1 <br /> 8067 East U Ave. Abe Northup �A <br /> MAIUNGAODRESSCITT Vicksburg STATE 419097 <br /> N 2 J <br /> SICCODE AP # /Y� 0O(^j COMMENT: M� <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY/ IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME CH2M HILL AmannoN:ORCARE OF (OPROAML) <br /> Abe Northup <br /> MAILINGADORESS 8067 East U Ave. PHONE 260-358-2165 <br /> CITY Vicksburg MI 49097 zip <br /> 49097 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNERO FAOILRYjBUSINESS0 THIRD PARTY BILLINGM <br /> SR.I3NI;ANn Q1a11•L1.\NCE AI'ENnwLF'.IX:ni6NT: L the undersigned Applicant certify that I am the Owner,OPeralor.Anlherce:L(eem.or Responsible Panp and 1 aclmm+led+e Ilial all PL ufff FYLS, <br /> PL.ell,"L,,L,v£ORCEAIE+TCH..+X(:cSNadler HOU'RtYb/1Ne.v;tsociatedwiththi3projectwill Ixbilldto Incattheaddr.id-ntifiadaWYeesthe ACMIWTADDR-'VfortMi site. 1also,PNfy Natall <br /> mfurnramm provided on thK appileal at v true And a rceq:ad that all',Ult 4vI activitimt out be performed!.I et,mrilmee with a0 applicable SAN JOAQIIIN COLNTv Ommetsec Cores and/or <br /> ST.\NHAW)Sand.TKrR andfor FADFRAI.Laws and R I.LL, PIONS.AS the undersigned Omen Opemmr,Amhnrr:eJ Agem.nr Raoprn.Ub/e Para•far the projeet located above under facility/site address,l <br /> hereby authorize the nkasc of any and all results•reports,and other cutirunmerved usessmew inrornmhon to SAN JOAQIIIN Cot 11 'YIRONSIRWAL EAUYHDEPAIITMENTaSSWIl ASit ISAVAilable <br /> and al the same time it u prmided to me or my reprewwat ive. <br /> APPLICANT NAME(PIEASE PRINT) Abe Northup SIGNATURE Q <br /> TITLE Project Manager TMID# 32-0100027 <br /> APPROV®BT I DATE ACCOUNTINGOFFKEPROCESSINDCOMPLETEDBY DATE <br /> SITE MITIGATION AMDUNTPAID DATE OF PAYMENT PAYMENTTYPE RECEIPT IS CHECK RECEIVED BY WORK PUN PE <br /> FEE;$ 375 37 ' ��30-13 ewer o�oa.oa 7086 Cou#TL-2 I a9 <br />