Laserfiche WebLink
SAN JQ^ UIN COUNTY ENVIRONMENTAL HEALTH SPARTMENT <br /> DATE 10/29/2012 MAER FILE RECORD INFORMATION "1 FR" GREEN FORM <br /> / SITE MITIGATION &LOP <br /> SHADEo AREAS FOR EHD USE ONLY OWNER ID# CASE 0 \(� / ! 2s/ UNIT IV <br /> DWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: l9V OwC/f/Ft7WNER/aCURRENTLYONFILE WITN EH a <br /> PROPERTY OWNER NAME / 1 <br /> FIRST 1411 LAST PHONE NUMBER <br /> BUaMmNAME San Joaquin Regional Rail Commission E-MAIL ADDRESS <br /> 8(L1&'J Acf f-A'I t_ . LD.4 <br /> OWNER HoMEAmwas 949 E. Channel St. <br /> CITY Stockton STATE CA LP 95202 <br /> OWNER MAIUNo ADmm 949 E. Channel St. <br /> MAILINGADDRMCITY Stockton STATE CA I ZP 95202 <br /> ®CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> UTE MITIGATION_ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP—WATER QUALITY_HW PIPELINE INVESTIGATION—LOP <br /> FACILrrY ID 0 INV# ACCOUNT ID PR IN RON ASSIGNED EMPLOYEE LEAD AGENOY:EHD_,.RWQCB—OTSC EPA_,_, <br /> J oHIL.0 y <br /> =ACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <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/FACI IWISITe1PROJECTNAME SJRRC MAINTENANCE FACILITY <br /> BITE ADDRESS I PRoJECr Lowen 1800 N. Marshall Ave. SurrE to BUSINESS PHONE <br /> CITY Stockton STATE CA zip 95205 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILJTY ADDRESS ATTENTION:ORCARE OF(OPnONAL) <br /> fdAILING ADDRESS CITY STATE zip <br /> SIC CODE It <br /> 0 1/ v COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME Antea Group ATTENTION:ORCARE OF(OPTJONAL) Lia Holden <br /> MaLINGADDRESS 312 Piercy Road S5 �. S, �� PHONE 408 826 1863 — Vdda . <br /> Cm San Jose STATE CA ZIP 9s�z <br /> 95138 / (( <br /> AMOUNT ADDREss TO SEND FEES AND CHARGES: OWNERO FACILfTY/BUSINESS❑ THIRD PARTY BILIJNG® <br /> O.t.ING Ar,D CO%IPLIA.NCE ACKNON LEDGMFvr: I.the undersigned Applicant,certify that 1 am the Owner,Operator,Aidhorized Agen;or Responsible Petry and I aclrnowledge that all PRRAor FEES, <br /> INua>IEs,ERFORCFMENT CRARCFJ and/or HOURLY CHARGES associated with this project will be billed to me at the address Identified above as the Acco[NT Aaamw for this site. I also certify that all <br /> Iformadon provided on this application is true and correct;and that all regulated activities pill be performed In accordance with all applicable SAN JOAQMN COUNTY ORMNA.YCE COD"and/or <br /> rA.NDARDs and STATE.and/or FEDERAL[.awn and RFGt IATIOYS. As the undersigned Owner,Operator,Authorized Agent,or Responsible Party for the project located above under facWty/site address,l <br /> ereby authorize the release of any and all results,reports,and other environmental aastsament information to SAN JOAQ0N COUNTY ENYrao�ffnrrm.HF.,U.TH DepAurvtVNT as soon as It Is available <br /> id at the same time It is provided to me or my representative <br /> APPLICANT NAME(PLEASE PRINT) S LE!a �� Sad SIGNAT — <br /> TITLE . TAxIDa 91-1839 97 <br /> APPROVED BY DATE ACCOUNTING OFRoe PRocEwmo CoupLETED BY DATE <br /> .sr _ <br /> SITE Oti7RIGATiON AMOUNT PAID DATE OF PAYMENT PAYYME/NT,TYP£ RECEIPT 0 CHECKKSr /s RECEIVED BY F <br /> ORKK PLAN PE <br /> FEE: (7�[(� v " C�u.vrG(� � / J U <br />