BILLING - Laserfiche WebLink

Home Browse Search

�7�San J-iquin County Environmental Healt' `apartment DATE 6/23/11 ,,,.STER FILE RECORD INFORMATION `%WR" GREEN FORM SITE MITIGATION & LOP SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV OWNER FILE:COMPLETETHEFOLLOW/NG PROPERTY OWNER/NFORMArlow CHECKIF OWNER CURRENnyoAt lLEN1TH EHD PROPERTY OWNER NAME Steve Giannecchini ) 209-931-5050 First MI Last PHONE NUMBER BUSINESS NAME Vacant E-MAIL ADDRESS Owner Home Address 3651 N Jack Tone Road city Stockton SCA zip 95215 Owner Mailing Address 3 6 51 N Jack Tone Road Mailing Address City Stockton S 95215 CORPORATION[:1INDIVIDUALM PARTNERSHIP❑ FED AGENCY❑ OTHER❑ SITE MITIGATION X ENVIRONMENTAL AsSESSME OLUNTARY CL P WATER QUALITY_HW PIPELINE INVESTIGATION_LOP FACILITY ID# INV# ACCOUNT PR#IRO# SIGNEg.C194-OYEE LEAD AGENCY:EHD_"-RWQCB,_DTSC EPA FACILITY FILE COMPLETE THE FOLLOW/ BUSINESS/FACIL /SITE(/NFORMAT/ON.' Is this a NEW Business LOCATION not previously r ited by the E MENTAL HEALTH DEPARTMENT? YES KI No ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No BUSINEss/FACILfTY/SITENAME Vacant SITE ADDRESS 2441 Giannecchini Lane SUITE# BUSINESS PHONE Cm Stockton, CA 95206 STATE zip BOARD OF SUPERVISOR DISTRICT LOCATION CODE I(EY1 KEYZ Mailing Address KDIFFEREATftmfaclWA Attention:orCare Of(opbbrial) Mailing Address City so# I W1 STATE ZIP SIC CODE APN# COMMENT: THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. BUSINESS NAME AEI Consultants , ATTN: Bryan Campbell Attention:orCare Of (opblonal) Mailing Address 2500 Camino Diablo PHONE (925) 746-6000 ext . 14 CITY Walnut Creek, CA 94597 STATE zip Accoye2ADnaEm for fees and Charges OWNER FACILITY/BUSINESSHIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOWLEDcetEnr: 1,the undersigned Applicant,certif} that 1 am the Onvner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERMIT Fees, PE.A'IL TIES,EnFORCcnreA'T C114RGss and/or HoCRLI CHARces associated eith this operation will be billed to me at the address identified above as the ACCOUWADDRess for this site. 1 also certify that all information prosided on this application is true and correct and that all regulated activities will he performed in accordance with all applicable SAN JOAQUIN COUN7l Ordinance Codes and/or Standards and SIA IL and/or FEDEIL4L Laws and Regulations. As the undersigned owner,operator,or agent of the properh located at the above facility/site address,I hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUN'n'ENX'IRONNfENTAL HEALTH DEPARTMEN s s s is available and at the same time it is prosided to me or nn representative. APPLICANT NAME(PLEASE PRINT) Bryan Campbell SIGNATURE TITLE program Manager TAxID#680288965 Approved By Date Accounting Office Processing Comple IML Data SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY ,WORK PLAN PE ' FEE:$