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San Joa---•in County Environmental Health P -artment <br /> DATE 6/23/11 <br /> /23/1177 MAS I ER FILE RECORD INFORMATION f1RI)RI) GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER I D#L/)000/a7u6&- CASE# UNIT IV <br /> OWNER FILE:COMPLETE TNEFOLLOW/NG PROPERTY OWNER/NFORMATION.� CHECKIF OWNER CURRENTLYONF/LEW/TH EHD <br /> PROPERTY OWNER NAME Steve Giannecchini 209-931-5050 <br /> First MI Last PHONE NUMBER <br /> BUSINESS NAME Vacant E-MAIL ADDRESS <br /> Owner Home Address <br /> 3651 N Jack Tone Road <br /> city Stockton SCA TE LP 95215 <br /> Owner Mailing Address 3651 N Jack Tone Road <br /> Mailing Address City Stockton States ZIP 95215 <br /> CORPORATION❑ INDIVIDUALM PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION X ENVIRONMENTAL ASSESSMEN VOLUNTARY C-EMkP_WATER <br /> �QUALITY HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INv# ACCOUNT PR#IRO# SIGNE� y!p�OYEE LED AGENCY:EHD_RWQCB_DISC_EPAFkxlvvq�Rw L— _ <br /> FACILITY FILE COMPLETETHEFOLLOWI BUSINESS/FACIL /SITE/NFORM47-10N: <br /> Is this a NEW Business LOCATION not previously r ted by the E MENTAL HEALTH DEPARTMENT? YES g] No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No <br /> BUSINESs/FACIIJTY/SITENAME Vacant <br /> $READDRESS 2441 Glannecchinl Lane SUITE# BUSINESS PHONE <br /> Cm Stockton, CA 95206 STATE zip <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> AL <br /> Mailing Address//DIFFEREA?bwn FedlliyAas Attention:orCare Of(opdone1) <br /> C I <br /> Mailing Address City ro f III <br /> STATE ZIP <br /> fft <br /> iltf�: <br /> COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME AEI Consultants , ATTN: Bryan Campbell Attention:orCare Of (opbbnal) <br /> Halling Address 2500 Camino Diablo PHONE <br /> (925) 746-6000 ext . 14 <br /> Cm Walnut Creek, CA 94597 STATE zip <br /> ACcouNTAODRE$S for fees and charges OWNER FACILITY/BUSINESSHIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOw LEDGMI'.N'1: 1,the undersigned Applicant,certify that I am the Ovrner.Operator,or Authorized Agent of this Business,and I acknowledge that all PERADT FF.E.S, <br /> PEAALT/Es,ENE0RCEA1ENTCl/4RGES and/or HOURL)01ARG&S associated ssith this operation will be billed to me at the address identified above as the ACCOUATADDRESS for this site. I also certify that <br /> all information provided on this application is true and correct:and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COL'NllOrdinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMEN s s .s is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) Bryan Campbell SIGNATURE <br /> TITLE program Manager TAxID#680288965 <br /> Approved By Date Accounting Office Processing Completed By Date <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE:�� -- <br />