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San Jraquin County Environmental Health 'lepartment <br /> DATE F <br /> Mp•'TER FILE RECORD INFORMATION "'wrFR"' GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOWWNG PROPERTY OWNER INFORMATION.' CHECK/F OWNER CURRENTLYONF(LEwrH EHD <br /> PROPERTY OWNER NAME Thien Phan (201 462-7621 <br /> First M1 aS PHONE NUMBER <br /> BUSINESS NAME E-MAILADDRESS <br /> California Stop calstop209@gmail.com <br /> Owner Home Address 2224 Manthey Road <br /> City Stockton PERMIT/SERVICES STATE CA zIP 95206 <br /> Owner Mailing Address 2224 Manthey Road <br /> Mailing Address City Stockton, CA state CA zip 95206 <br /> CORPORATION❑ INDIVIDUAL I:2 PARTNERSHIP❑ FED AGENCY❑ OTHER❑7 <br /> SITE MITIGATION_ENVIRONN;ENTAL ASSESSMENT_VOLUNTARY CLEANUP WATER QUALITY HW PIPELINE INVESTIGATION LOP <br /> FACILITY I D# INV# ACCOUNTID PR#/ ASSIGNED EMPLOYEE LEAD AGENCY:EHDRWQCB_DTSC EPA_ <br /> CIO <br /> FACILITY FILE COMPLETE THEFOLLOWING BUSINESS/FACILITY/SITE INFORMATION." <br /> Is this a NEW Business LOCATION not previously regulated by the ENviRONMENTAL HEALTH DEPARTMENT? YES ❑ No fN <br /> Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESSIFACIUTY/SITENAME California Stop <br /> SITEADDRESS 2224 Manthey Road SUITE# BUSINESS PHONE <br /> CITY Stockton STATE ZIP <br /> CA 95205 <br /> BOARD OF SUPERVISOR DISTRICT `/', / LOCATION CODE O I KEy'I I( <br /> Mailing Address KO/FFERENT from FacllityAddress t Attention:orCare Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODEAPN# COMMENT: <br /> /VtI- (3c-)-b <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BJSINESs NAME ADVANCED GEOENVIRONMENTAL, INC. Attention:orcare Of (optional) <br /> Mailing Address 837 SHAW ROAD PHONE <br /> 209-467-1006 <br /> Cm <br /> STOCKTON STATE CA zip 95215 <br /> for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE Agoowi.EDCMENi': 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or.-authorized Agent of this Business,and I acknowledge that all PERMIT FEFv, <br /> PEN41.17Ev,ENFOR(EMENI'CHAR(;F-v and/or HOURLYCHARG6v associated with this operation will be billed to me at the address identified above as the ACCOUNTAUURFS4 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 SAN JOAQtRN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAI.Laws and Regulations. As the undersigned owner,operator,or agent of the property, located at the above facility/site address,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) TIMOTHY J. CUELLAR SIGNATURE <br /> TITLE PROJECT MANAGER TAx ID# <br /> Approved B Date Accounting Office Processing Completed By Date <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORKPLAN PE <br /> FEE:f '"J1 •-j� <br />