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San J( An County Environmental Health F artment DATE Z MASTER FILE RECORD INFORMATION"MFR" 1'CR�r� GREEN FORM SITE MITIGATION & LOP $HApm AREm"EMD m OmUNIT 1V OvnlLgt IDS OASE# - �rz�c,Uy7S OWNER FILE:COMPLETETHEFOLLOW/NG PROPERTY OWNER/NFORMA770N.- CHecKls OWNER CuaREvnroNFxEwrrH EHD PROPERTY OWNER NAME N/A N/A N/A (801) 365-4606 First Ml Last PHONE NumeaR BusodEss NAME E-"L ADOREss Extra Space Properties Seventy Four LLC N/A Owner Home Address 2795 East Cottonwood Parkway#400 City F11TATE ZIP Salt Lake Cit h 84121 Owner MsI*V Address Same as above Ma WV Address City Stade Zip Same as above Same as above CORPORATION® INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ Srfa MmaATIION_ENVIRONMwTAL A1tsanuENT_A_VOLUNTARY CuL^NUF_WAT=QUALffy_HW PIPE1JNN IWARSTI ATION LOP FACILITY ID R INV# ACCOUNT ID PR#/Rio# F/� sstaNm EMPLOYEE LEAD AaENcY:EHD�-RWOCS__,OTSC EPA 1 FACILITY RILE COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE/NFoRMAwN.- Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES No Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES No ❑ BUSINEs&TAciLRY/SITE NAME Extra Space Storage SITE ADOREBs SUITE# BU81NEM PHONE 55 East Jamestown Street Cm STATE ZIP Stockton California 95207 _j BOARD OF StwERvrsoR DISTRICT LOCATION CODE KEYi KEY2 �I Malting Address HDIFFERENTfiarn FacNfyAddrlass Attention:orCaAre Of(opHonoug Mailing Address City STATE ZIP SIC CODE APN#/J y- /C `C COMMENT: THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFacility Operator identified above. BusimEss NAME Attention:orCars Of (opbfarW Mailing Address PHONE CITY STATE ZIP �-AwCowr _ for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING BILLING AND COMPLIANCE ACKN0WI,EM;NENT: 1,the undersigned Applicant,certify that 1 am the Onner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PER.wrFEES, PIv.-U.TtES,ENFURCEMFNTCH4itwFS and/or HOURI.f CH.ARGF_S associated with this operation will be billed to me at the address identified above as the+COCVTADDRESU'for this site. 1 also certify that all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with alW7��111 N COOYIl Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the 1 hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONNIENTAL HEALTH DEPARTrilable and at the same time it iv provided to the or my representative. APPLICANT NAME(PLEASE PRINT) CHARLES L ALLEN SIGNATURE TITLE TAX ID# 45-4282262 Ap roved—Bir _��- DTb _ A000imtnq Ofnca ProcwalnQ C«r Mtod B Date Bill! BITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECKS RECEIVED BY WORK PLAN PE FEE:$ �71 3 7`- j<F,f ?,&),Z F L�j /60