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EnvironmentalHealth
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EHD Program Facility Records by Street Name
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ACAPULCO
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8635
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3000 – Underground Injection Control Program
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PR0516473
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Entry Properties
Last modified
2/11/2020 11:21:32 PM
Creation date
2/10/2020 11:26:09 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
3000 – Underground Injection Control Program
File Section
BILLING
RECORD_ID
PR0516473
PE
3030
FACILITY_ID
FA0012629
FACILITY_NAME
AHMAD RESIDENTIAL PROPERTY
STREET_NUMBER
8635
STREET_NAME
ACAPULCO
STREET_TYPE
WAY
City
STOCKTON
Zip
95210
CURRENT_STATUS
01
SITE_LOCATION
8635 ACAPULCO WAY
P_LOCATION
01
QC Status
Approved
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Tags
EHD - Public
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Say Joa ui Caunt TttC He I h 5..ices ..... m ktealth D>IvisTvn <br /> DATE MASTER FILE RECORD INFORMATION FORM (EH0015(REwsED08f11t9T) <br /> sa�aeeesr�4�fHo vse.Q■iz <br /> UNIT IV <br /> OWNER FILE <br /> 7I� L EFOLLI�Y(NGBUSINESS OWNER /NFORMAT(ON: CHEcKtr OWNER CURAENTLYONFILEwrrHEHO <br /> ,t ............. ... ................................................................................... ........................................................................................ 9.-..-................... <br /> BUSINESS 1L1 <br /> PHONE <br /> 9,S7 <br /> 7OWNER NAME - ——- _ ---- ----- —ZI <br /> ' <br /> ..........................................................Firs(.......................................MI................................ .... .m.. A,; .. <br /> BUSINESS NAME(If different from Owner Name) C/TAX 10 <br /> OWNER HOME ADDRESS L/3 y SPR I NP 1\I 1 4 P` C1 j,, i DRIVER'S LICENSE# AJ47 JS l 1jY Q <br /> city 7 / ENVIRONMENTAL HE41MTIV 71P " / <br /> 9 ck <br /> OWNER MAILING ADDRESS (if D/FFERENTfromOuvr►erAddress) <br /> '. Attention:or Care of (optional) <br /> Li o <br /> Mailing Address City ' State zip <br /> CORPORATION❑ IVIDUAL EI--_"PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY'1 #.. J ts3B IiEE:t[# <br /> COMPL ETHEFOLLOWING OSINESS / FACILITY I SITE INFORMATION: <br /> 11 <br /> Is Ibis at8usiness LOCATIO_wnrot previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ NO ❑ <br /> Is this anJ Busirtess LOCATION but a NEW TYPE of regulated Business? YES O NO ❑ <br /> BUSINESS/FACILITY/SITE NAME �'� y/ ,� ,J J „I •y_.:�r (_I (t/n� CJ <br /> SITE ADDRESS , t '� SUITE# BUSINESS PHONE <br /> CITY ST/yTFn ZIP <br /> 1OcjmnNrnn#:: J&4 <br /> Mailing Address if DIFFERENT from Facility Address E Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE J <br /> i .. >: 'COMMEM' <br /> RPf k# <br /> THIRD PARTY BILLING INFORMATION: C.0! p"t if Billing Party is different from Business Owner Identified above. <br /> .................................................................................................................f............................_....---....................................,........................_................................................................................_..., <br /> BUSINESS NAME % Attention:or Care Of (optional) <br /> i <br /> Mailing Address E PHONE <br /> CITY / STATE ZIP <br /> ACCOUNT-ADDRESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> l3I1.I.FNC.:WD CO,MPLINNCE AC"OWLF.DGMENT: I,the tm ant,certify that I am the(honer,Operator,or Authorized Agent of this Business,and I acknowledge that all <br /> PER.tflr FF-FS, PF.N,ILTTFS, FNFORCF)tfFNr CHARGES and/or KOURLY CNARCET associated with this operation will be billed to me at the address identified above as the ICCOuvr <br /> .lnnRF.cs for this site. I also certifv that all information provided on this application is true and correct; and that all regulated activities will he performed in accordance with all <br /> applicable SAN JOAQUI N COUNTY Ordinance Codes and/or Standards and STATE,and/or FEDERAL laws and Regulations. As the undersigned owner,operator,or agent of the propertv <br /> located at the above facility/site address. I hereby authorize the release of anv and all results and environmental assessment information to SAN -JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME S �f� SIGNATURE <br /> DRIVER'S LICENSE# { <br /> TITLE �i/� R <br /> Appro"ed Oy Date Accounting Offlee Processing Gompteted By bate00 <br />
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