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San J uin County Environmental Health lartment <br /> DATE 2 29-I Z MASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> '('C SITE MITIGATION & LOP <br /> $HApw ARzAs Rin EMB use ONLY OWNER 10/ CASES Skcx�4 y y 7 S UNIT I V <br /> OWNER F1LE:00MPLE7ETHEFOLLOWING PROPERTY OWNER/NFoj?mATiON: CwcKIF OWNER CuowEanvavmEwnH EHO <br /> PROPE"'Ow""'N"m N/A N/A N/A (801) 3654606 <br /> First M/ Last PHONENu m <br /> BUSINESS NAM E umt.ADDRESS <br /> Extra Space Properties Seventy Four LLC N/A <br /> O*Tw Homo Address <br /> 2795 East Cottonwood Parkway#400 <br /> City STATE A► <br /> Salt Lake City Utah [84121 <br /> Owner Malting Address <br /> Same as above <br /> Malift Address City Stab Zip <br /> Same as above Same as above <br /> CoRroRAnoN® INDIVIDUAL❑ PARTHOMW❑ FED AeoicY❑ OTHER:❑ <br /> Srm UfT1aAmN_EwRONMl1TAL AssaamarT VoLuwARY Cu mss_WATot QuwtrrY_HW Pipsum lwnsmAmN_LOP <br /> FAcam 10 0Itrue AcCaLmT 10 PR u RO 1 AsswwD ErPLaveE LEAD Aootor.EHD X RWQ=_01 _EPA_ <br /> l2� 4*�3� 5it�38� . 49 <br /> FACILITYFILE ComPLETETHEFOLLOwINGBUSINESS/FACILITY/SITE/NFORM4TION: <br /> Is this a NEw Business LOCATION not prevkxnfy regulated by the ENVIRONMENTAL F'IEALTH DEPARTMENT? YES 49 No,Ej <br /> Is this an EXISTING Buskless LOCATION but a NEw TYPE of regulated Buskmiss? YES No ❑ <br /> BUSINEMiTACILITYISITE NAW <br /> Extra Space Storage <br /> SITE ADDRESS SUITE sr BUSINEU PHONE <br /> 55 East Jamestown Street <br /> CITY STATE ZIP <br /> Stockton California 95207 <br /> SCAM Or EUPGRYOM DISTRICT LOCATm Coos Kart T KEY2 <br /> Mailing Address IMFFEREArrflam FAcAWAddrem Attention:orCare Of(opdattiag <br /> U&MV Address CHy STATE ZIP <br /> SIC Cooc <br /> AM* Caaretr. <br /> THIRD PAwrY BILuma INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> ivBuetNES6NAaaE (✓Y�J yi /1-0�J AtLrtffon:grCareaC( 0 <br /> N' <br /> 1� <br /> e� &MagAddress 0p I S!-f't:�Mzut,ib Jj ' Tfe 7D 0 PHONES!0) (DSS-7VCC <br /> v+ CITY I STATEVt r ZIP <br /> J('�y <br /> AppoixTADDAgm for teas and chargee OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEIKM1fENT: L the undersigned Applicant,certify that I am the(hums,Operator,or Audtorized Agent of"Business,and I aclmowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEAfEMCH1RGES and/or HoURLYCILIRGES associated with this operation will be billed tome at the address identified above as the ACCVUVTA 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 N JOA COUNn Ordinance 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 f /site dr I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN n it' ailable and at the same time it is <br /> provided to me or my representative <br /> APPLICANT NAME(PLEAse PRIHr) CHARLES L ALLEN SIGNATURE <br /> TITLE TAx ID� <br /> CA I-)(- t. - .r 45-4282262 <br /> Appro-d Dots M"00 <br /> 6TTtt MTTTaATtoN AAt)tllrr PAID DATE Of PAYIIE T PAYrew TYPE Recetrr 0 CHECK 0 Recum BY WORK PLAN PE <br /> Fee1�7s 3 -? �(� l7, zai i�v5� ?CvoU Ce Z� <br />