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SAN JOIR6UIN COUNTY ENVIRONMENTAL HEALTH DNIARTMENT <br /> DATE11 4/16/13 � MASTER FILE RECORD INFORMATION«MFR'9 GREEN FORM <br /> n SITE MITIGATION &LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID/ CASE R 5RON-7o 17 UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK/FOWNER/S CURRENTL Y ON FILE WITH EHD O <br /> PROPERTY OWNER NAME Margaret Marci 7( 07) 465-6015 <br /> FIRST MI LAST PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> OWNER HOME ADDRESS 20 Mobile Lane <br /> CITY Crescent City STATE CA ZIP 95531 <br /> OWNER MAILING ADDRESS Same as above <br /> MAILING ADDRESS CITY STATE ZIP <br /> ❑CORPORATION IJINDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION X ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILm ID* INvt AccOUNT ID PR iN RO* /i 1GfrL tp� XGENc7•t 1�S 1N C8 I� -- E " <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: 7� <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 /> BUSINESS/FACILITY/SITE/PROJECT NAME Marci Property <br /> SITE ADDRESS/PROJECT LOCATION 2969 Loomis Road SUITE# BUSINESS PHONE <br /> CITY Stockton STATE CAZIP 95205 <br /> BOARD OF SUPERVISOR DISTRICTT I <br /> LOCATION CODE / KEW KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:OR CARE OF(OPTIONAL) <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE APN# /7?- <br /> 79- (/o - 2 �� COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ATTENTION:OR CARE OF (OPTIONAL) <br /> MAILINGADDRESS <br /> STATE zip <br /> Cm <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNERffX FACILITY/BUSINESS❑ THIRD PARTY BILLING❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: [,the undersigned Applicant,certify that 1 am the Owner,Operator,Authorized Agent,or Responsible Party and 1 acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLYCHARGES associated with this project will he billed to me at the address identified above as the ACCOUNTADDRESS for this site. I also certify that all <br /> 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 t)RDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operator,Authorized Agent,or Responsible Party f 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 CO IRON FEN H DEPARTNIENT as soon as it is available <br /> and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) Rayno 1 d Kab 1 anow SIGNATURE - <br /> TITLE Authorized Agent - TAXID# <br /> APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE `✓ /� <br /> SITE MITIGATIO AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT A CHECK 0 RECEIVED BY WOlMS PLIIRK <br /> FEE:$ V 92 o <br />