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SAN J JUIN COUNTY ENVIRONMENTAL HEALTI ?PARTMENT <br /> DATE 10/29/2012 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> '1 / SITE MITIGATION&LOP <br /> SHADED AREAS FOR END 118E ONLY OWNER I DN /�1 1 00 1 13 O E CASE g �Q/.y�/ ( UNIT IV <br /> DWNER FILE:COMPLETE PROPERTY OWNER/RESPONS113LE PARTY INFORMATION: (g(/ CHECK IFOMER/8 CuRRENTLYONRLE W?H END a <br /> PROPERTY OWNER NAME <br /> FIRST MI LAST PHONE NUMBER 10 5- <br /> BUstNESS NAME E-MAIL ADDRESS <br /> San Joaquin Regional Rail Commission IS04AP AcfLOrI` Caw-% <br /> OWNER HOME ADDRESS 949 E.Channel St. <br /> CITY Stockton STATE CA LP 95202 <br /> OWNER MAIUNOADDRESS 949 E.Channel St. <br /> MAIUNaADDRESS CITY Stockton STATE CA LP 95202 <br /> ®CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> ;ITE MITIGATION_ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY IDS INV/ AccouNT 10 PR$1 RO/ ASSIGNED EMPLOYEE LEAD AGENoY:EHD-X-_RWQCB—OTSC_EPA <br /> .'2 S3_7 3 53 53 J 0/4IUA/y <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> IS THIS AN ERISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ® No ❑ <br /> BUSINE991FACSJTY/8ITEMMECTNAME SJRRC MAINTENANCE FACILITY <br /> SITE ADDRESS I PROJECT LOCATION 1800 N. Marshall Ave. SUITE S BUSINESS PHONE <br /> CITY Stockton STATE CA 2JP 95205 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE ' KEY1 rKEY2 <br /> MAIuNa ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTWNAL) <br /> MNume ADDREss CITY STATE ZIP <br /> SIC CODE APN p l/7 ,U(�v _ I COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINE68 NAME Antea Group ATTENTION:OROARE OF(OPTIONAL) Lla Holden <br /> MAIUNOADDREss 31 oa - l' C 5 A r / 5! �� PHONE -408$26_1'863 Vde <br /> CITY San Jose J Iy l STATE CA 7JP81 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILnT/BUSINESS❑ THIRD PARTY BILLING® <br /> TLLING AND COMPLIANCE ACKYON LEDG%IENT: I,the undersigned AppUtant,certify that I am the Owne,Opffator,AudwrW Agen4 or Responsible Parry and I aclmoaledge that all PERWTFE" <br /> IMAM&%ENFvAca mw CAARam and/or H0URLYC7LWGU associated with this project will be billed to me at the address Identified above as the AcwtWT AI wFm for this alto. I also certify that all <br /> dormation provided on this application L true and correct;and that all regulated activitrn will be performed In accordance with all applicable SAN JO4 mN Covmv ORDINANCE CODES and/or <br /> rANDARns and STATF,and/or FEDERAL Lava and REGI IATIONs. As the undersigned Owner,Operator,ARdhor$ed Agent'or Responsible Parry for the project located above under facWty/site address,l <br /> ereby authorize the release of any and all results,reports,and other environmental assessment Information to SAN Jo.4%UN COUNTY E "--rAL AF.ALTN DEP as anon as It is avallable <br /> id at the same time it Is provided to me or my representative. <br /> APPUOANTNAME(PLEASE PRINT) S'AC.f.N O(Ln�JS SIGNAT <br /> TmE ��✓� �`�f. i � TA"O s 91-1839 97 <br /> �J I /l <br /> APPt10V[OBY oA,e AOOOIRtiWOOFFpEPROl7�OR1GC01MLSTEDBY LLCi- DATE I L <br /> SITE MITIGATION AMOUNT PND DATE OF PAYMENT PAYMENT TYPE RECEIPT P CHECK R REOEIVEO BY [WORK PLAN PE <br /> FEE:III 3'? -S?5- <br /> 12-,�-IU (�-q x 1 1 <br /> 6 L CowurC-.!i_ <br />