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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATEQ �3 I� MASTER FILE RECORD INFORMATION EdMFR)a GREEN FORM <br /> { ///���ttr It SITE MITIGATION& LOP <br /> DHAOED a REASFOREHOUSEONLY OWNER ID# s' / �� CASE# v0�`(�/1O(ic UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CNecKiFOwNERfs CuRRENTLro FREwirREHD � <br /> PROPERTYo:w E. NA I DanielW Munzer (562)283-1014 <br /> M/ ST % PHONE NUMBER <br /> BUSINESS NAME Mun- .InaDLJ It ADDRESS <br /> dmunzer@muncot.com <br /> OWNERHOMEADDRESS <br /> 3450 E.Spring Street,Suite 218 L, <br /> Cm Long Beach C CAE ��'' 90806 <br /> OWNER MALUNG ADDRESS 3450 E.Spring Street,Suite 218 Z� <br /> MARINGADDREESCm Long Beach v V 'TAA 90806 <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENTACENCY IN RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INv# ACCOUNTID PR#/ O# ASSIGNEDEMPLOYEE LEAD AGENCY:EHD_RWQCB_DTSC_EPA_ <br /> `101 Da <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> ISTHISANEW PROJECTLOCAnoN NOT PREVIOUSLY REGULATED BYTHEENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No <br /> BUSINESS/FACILITY/SiTE/PROJECTNAME Koppel Stockton Terminal <br /> SITE ADDRESS I PROJECT LOCATION 2025 West Hazelton SURE# BUSINESS PHONE <br /> Cm• Stockton STAzip <br /> CAS 95203 <br /> BOARD OF SUPERVISOR DISTRICT /v LOCATION CODE D KEYT KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> 8067 East U Ave. Abe Northup <br /> MAIUNGADDRESSCITY Vicksburg STATE 2419097 <br /> SIC CODE APN# /,/r OQ-\^OG f:OMMENT: MI <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESSNAME CH2M HILL ATTENTION:ORCARE OF(OPTLONAL) <br /> Abe Northup <br /> MAILINGADORESS 8067 East U Ave. PHONE 269-358-2165 <br /> CITY Vicksburg STATE ZIP <br /> MI 49097 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNERD FACILDYIBUSINESSE1 THIRD PARTY BILLING® <br /> BILLIM':AN)COMPLIANCfi.1fHNONLROGNIENY: I,lite undersigned Applicant,certify It.,Ism he Oa'llfq Jpernlnr,dnrhnri3ed.IgrN,nr Relponsib/a Pnrp•and IscknmHLdgeth.tsA prWri-FEES, <br /> P6wrlLe.6VFORCEAfE1T CN,uM.eS andTor J/44'RT.)'CN.1kcF3 asenci4ed will.Ibis pr.jcc'I,ill be biked to nm at O¢address irkntif d above as the ACCOLWTADDRM for this site. I also certify that all <br /> Infurnladen pewided On Ihii application is huc And correct;and that.11 rbula4d acfitili Will Ill•perfiinlnV in:Il'lwdantt with all applicable SAN JOAQUIN COUNTY ORDINANCE CODTS And/Or <br /> $f:\AII:IROS;,nd STATd and/Or PRDRR.11.?ANS and RECGL"toNS.AS the onderaigned Oxm[q 0Y.Pi,AnrGvri�dd;;enL or Rmfuresible PaFV for the project located above ander(achy/site address,l <br /> Inrcby authorim the rcle:rte of a.iy and all rASULA,reports,and other eneirunmenml ass\ssnknt infornA,itm to]'AS JOAQCIF Ct1UhT}^�pAl'YIA06h1ENf.4L/H�EU.TLI DEP.\IMIENTaS SOOn NS it IS aVailUbIC <br /> and At Elie same lime it Prvrvided to meor my repretsnialh, <br /> APPLICANT NAME(PLEASE PRINT) Abe Northup SIGNATURE <br /> Tine Project Manager Tmio# 32-0100027 <br /> APPROVEO BY DATE ACCODNTNG OFFICE PROCESSING COMPLETE)BY ATE <br /> SrEMITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECKS RECEIVED BY WORK PLANPE <br /> FEE:: 37S 37 ' 13-3°-'3 C1-ee-F 0�0 a,os �org� eolY„/><R a9 <br />