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EHD Program Facility Records by Street Name
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HAMMER
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1210
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2900 - Site Mitigation Program
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PR0539536
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Entry Properties
Last modified
2/19/2020 4:07:02 PM
Creation date
2/19/2020 2:37:14 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
BILLING
RECORD_ID
PR0539536
PE
2950
FACILITY_ID
FA0022618
FACILITY_NAME
VALERO #3641
STREET_NUMBER
1210
STREET_NAME
HAMMER
STREET_TYPE
LN
City
STOCKTON
Zip
95210
APN
09403012
CURRENT_STATUS
01
SITE_LOCATION
1210 HAMMER LN
QC Status
Approved
Scanner
SJGOV\sballwahn
Tags
EHD - Public
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i 1 <br /> I <br /> San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED ARFaaFOR EHO USE ONLY OWNER ID# OASE/ - UNIT IV <br /> OWNER FILE:CoMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMA not: CHECK IF OWNER CURRENTLY ON FILE W1rH EHD <br /> PROPERTY OWNER NAME <br /> First v M111 Las? \PHONE/NUMBER J / <br /> BUSINESS NAME ff � E-MAIL ADDRESS <br /> �i{ www Lt6 - FD w{•5 C5� (Gut�S,cow <br /> Owner Home Address <br /> City STATE LP <br /> Owner Melling Address <br /> Mailing Address City (�J � State <br /> K 7 <br /> 1319b <br /> ORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY I KRESPONSIBLE PARTY ❑OTHER <br /> 1 MITIGATION_ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP_ <br /> FACILITY 10 INV* AccouNrlo PRi�/ldI' IK' AelliONEDEIYaLOYEE'� LEtw.AoEtvaY EHO RWgCB_DTSC_EPA_��, <br /> j%p-pQ22lpl�• �DDU-('�� f�S��I�r •.lotfi+j <br /> FACILITY FILE: COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> Is this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No`� <br /> IS this an EXISTING Project LOCATION but a NEW SCOPE OF WORK? YES ❑ No <br /> IC <br /> BUSINE99IFACILITYISITEIPROJECT NAME vel <br /> SITE ADDRESS I PROJECT LOCATION V(/ I� `j I SUITE# BUSINESS PHONE <br /> 2- <br /> CITY ( � STAT F„) <br /> A ZIP ^ <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE U/ KEYS KEYZ <br /> Mailing Address ff DIFFERENTfrom FacilityAddress Attention:orCare Of(optlonall <br /> Melling Address City I STAT zip Q Z_C <br /> C <br /> 31C CODE APN# COMMEtiT: <br /> 2- <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Responsible Party identified above. <br /> BUSINESS NAME AttenUon:orCare Of(optlonal) <br /> Mailing Address PHONE <br /> CITY STATE zip RECEIVED <br /> A a NTAODR ss for fees and charges OWNER FACILITY/BUSINESS THIRD PAR7 BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDCAIENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,AntborizedAgent,or Responsible Party and I acknoe�,.r7 �t1lIR7Codes <br /> TY <br /> PENALT/FS,&VFORCEAflM'CHARGES and/or HOURLYCIMRCER associated with this project will be billed tome at the address identified above as the ACCOUNTADDRES4 forth information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinancan T <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned Owner,Operator,Authorized Agent,or Responsible Party for the project located above under facility/site address,1 <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it <br /> is available and at the some time it is provided to me or my representative. <br /> 7 <br /> APPLICANT NAME(PLEASE PRINT) �^(j M�� �^ �� if\ SIGNATURE <br /> � 1\� ,�r1 TAxID# g4-II 2 uta 5 I <br /> TITLE L\ \ ,— V: r WV\k <br /> Approved By Oete Accounting Once Processing Completed By Date <br /> SITE MITIGATION AMOU�NyT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHHECCK# RECEIVED BY WO K PPLCAN PE <br /> FEES 39'O 3lU / G�/,�II� L -- -- - Z41� G6Gtar�e /�IJQ <br />
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