Laserfiche WebLink
SAN JWIN COUNTY ENVIRONMENTAL HEALTH SIARTMENT <br /> DATE 2/4/13 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> ////����rrrr 44465 UNIT IV <br /> 8 AS FOR END 08E ONLY OWNER ID# 52 7 CASE# ��/_4 77 <br /> OWNER FILE:COMPLETE PROPERTY OWNERI/RESPONSIIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH END <br /> PROPERTY OWNER NAME Li nYA�F'1 Pr11 eJ LJ�D (209)478-9200 <br /> FIRST MI L45T PHONE NUMBER <br /> C-MAILADD0.ES8 <br /> BUSINESS NAME <br /> Sims-Grupe Management CovpD�-a h"oma, <br /> OWNER HOME ADDRESS <br /> CRY STATE ZIP <br /> OWNER MAIIJNGADDRESS 374 Lincoln Center <br /> MAILING ADDRESS CRY Stockton STATE CA I ZIP 95207 <br /> X CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_ WATER QUALITY HW PIPELINE INVESTIGATION_ _LOP <br /> FACILITY 10 INV# AccoUNTID PR RO# ASSIGNEo EMPLOYEE LEAD AGENCY:EHD_RWQCB OTSC_EPA— <br /> D,53-7L37 �CIfaN <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 EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES bC No ❑ <br /> BUSINESSIFACILITYISITEIPROJECTNAME Lincoln Center Environmental Remediation Trust <br /> SITE ADDRESS I PROJECT LOCATION 6475 Pacific Avenue (rear) SORE# BUSINESS PHONE <br /> CITY Stockton STATE CA ZIP 95207 <br /> BOARD OF SUPERVISOR DISTRICT I LOCATION CODE / KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS 3043 Gold Canal Drive Suite 201 ATTENTION:ORCARE OF C/o Joe Niland, Trustee <br /> MAILING ADDRESS CITY Rancho Cordova STATECA IJF 95670 <br /> SIC CODE APN# COMMENT: <br /> 11 052-c( <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESSNAME Geosyntec Consultants Inc. ATTENTION:ORCARE OF IOPTICNAL) c/o Joe Niland <br /> MAILING ADDRESS 3043 Gold Canal Drive Suite 201 PHONE 916-637-8325 <br /> CITY Rancho Cordova STATE CA ZIP 95670 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING[X <br /> BILLING AND COMPLIANCE ACIONOW LEUGMENT: 1,the undersigned Applicant.Serfify that 1 am the Owner,Opera MG,Ami ortzed AReIR,or Respan able Party Bud I acknowledge that all PERMIT F£E,c, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURIYCHAR(:ET associated with this project will be billed to me at the address identified above as the ACCOum'ADDRESS for this si . 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 COUNT RDt.ANCE CODES and/or <br /> STANDARDS and STATE and/ r FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operator,Authorized Agent,,or RC ponSlble Pandy for the projest I ted 860 aMl¢r BCIIIIy/9ite 8ddreS4,1 <br /> hereby authorize the release of any and all resale,reports,and other environmental assessment information to SAN JOAQUIN COU VIRONMENTAL HEA DEPAR MENT as n as it ts available <br /> and at the same time itis provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) Joe Niland SIGNATURE \ <br /> TITLE Principal, Geosyntec Consultants THRID# 59- 5513 �T <br /> APPROVED BY DATE ACCODNTN.OFFICE PROCESSING COMPLETED BY DATE P� <br /> SITE MITIG TION AMOUNT PAIp DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAIN PE <br /> FEE:; �O <br />