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San Jc lin County Environmental Health C artment <br /> DATEi MASTER FILE RECORD INFORMATION"MFR" ( GREEN FORM <br /> 2.2q� <br /> SITE MITIGATION & LOP <br /> %HADW ABsA_f4R EHD usE ONLY OWNER IDSCAI10 �kw 4 y y 7 UNIT IV <br /> OWNER FILE:COMPLETETHEFOLLOW/NG PROPERTY OWNER INFORMATION: CmrcxiF OWNER CuHRENTLyoNFILEwm7 EHD <br /> PROPERTY OWNER NAME N/A N/AN/A (801) 3654606 <br /> First Ml Last PHONE NUMSER <br /> BusmEsa NAME E-MAIL ADOREBE <br /> Extra Space Properties Seventy Four LLC N/A <br /> Owner Home Address <br /> 2795 East Cottonwood Parkway#400 <br /> Cky STATE ZIP <br /> Salt Lake City Utah 184121 <br /> Owner Malting Address <br /> Same as above <br /> WWting Address Cky Stabs Zip <br /> Same as above Same as above <br /> CORPORATION® INDMDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SfTla MtT1aATwH_11NvIRoNmnNTAL Assanuerrr VOLUNTARY CLNAMur_WAT=QuALrrT_HW PIt•wm ImvzsTIaATIION_LAP <br /> FACILITY ID R INV$ ACCOUNT ID PR 01 RO• AswaNED EMPLOYEE LewD AoENcY:EHD X RWQCB OTSC EPA <br /> FACILITY FILE COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE/NFoRMAnoN: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES VNO.E! <br /> Is this an ExisTING Business LOCATION but a NEW TYPE of regulated Business? YES E] No ❑ <br /> BUS wm1FAaLm 1SrrE NAME <br /> Extra Space Storage <br /> SITE ADDR&ss SUITE# BUSINESS PHONE <br /> 55 East Jamestown Street <br /> CITY STATE ZIP <br /> Stockton California 95207 <br /> BOAtmaFSLwERVIsoaDtsTwcT Lounow CooE KEY1�--�—--'_—---f KEr2— <br /> MaNing AddressNDIFFEREWTfivm FacMiRvAddrvse Atberttlon:or `Core Of(op ibna/f <br /> Malting Address Cky STATE ZIP <br /> SFC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> Bume3s NAME Atbantion:orCare Of (opNonag <br /> MaHkV Address PHONE <br /> CITY STATE Zip <br /> TALUDAgm for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOW'LE.DGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or AudiorizMAgent of this Business,and I acknowledge that all PERaor FEES, <br /> PEK41,77E.S,Eh'FURCEA(EVTCHAR(;hS and/or HOURLYCHARGES associated with this operation will be billed to me at the address identified above as the ACCothy7AUDREf;c for this site. 1 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 N COurrn*Ordinance Codes and/or <br /> Standards and S7ATE and/or FE.DEFIAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above f ' /site dr ,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNT}'ENVIRONMENTAL HEALTH DEPARTMEN a 96on it js ailabie and at the same time it Lv <br /> provided to Ire or my representative. <br /> APPLICANT NAME(PLEASE PRINT) CHARLES L ALLEN SKMATURE <br /> TITLE TAx ID it <br /> 45-4282262 <br /> _. owed B Dab ]: Accoun OM%C4 Pr ocartry Coenplabd By _ Dab <br /> SITE MmGATION AMOUNT PAID DATE OF PAYMENT PAymen TYPE RECEIPT/ CHECK S RECEIVED BY WORK PUN PE <br /> FeerP5— 3 7 �C-i /71 z01 j T !LL U 5� 1 e Ce 7 <br />