Laserfiche WebLink
SAN JOA COUNTY LNVIRONMENTAL HEALTH L) RTMENT <br /> BATE 2/5/2014 MASWIR FILE RECORD INFORMATION 96 At GREENFORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHD ONLY OWNERID# CASE# UNIT IV <br /> vw � ovU 2q�4 SRcn�9 00 <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFO ON: CHECR IF OWNERis CURRENTLr ON FILE HI END <br /> PROPERTY OWNER NAME (209)839-4065 <br /> FIRST Ml LAST PHONE NUMBER <br /> SUSINE E E-MAIL ADDRESS <br /> DLA Share Depot maurice.benson dla.mil <br /> OWNER NNE ADDRESS <br /> 25600 Chrisman Road <br /> Cm STATEP <br /> Trac L <br /> CA 95304 <br /> OWNER MAILING ADDRESS <br /> P.O. Box 960001, Bldg 100 Rm 2 <br /> MAILING ADDRESS CITY STATE LP <br /> Stockton M CA 95296-0710 <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP I GOVERNMENT AGENCY <br /> ❑RESPONSIBLE PARTY 1:1 OTHER <br /> SITE MITIGATION X ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> FACILITY ID#1 INv# ACCOUNT ID PR#IRO# =Assj1G"EDVE'M1rL0YEE LEAD AGENCY:EHDY RWgCB_OTSC_EPA_ <br /> 41 <br /> to(IVA <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No P9 <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No <br /> BUSINESS/FACILmISUEIPRWECT NAME 91 <br /> Diamond Pet Food <br /> SUE ADDRESS/PROJECT LOCATION SURE# BUSINESS PHONE <br /> 250 Roth Road 209-983-4900 <br /> CITY <br /> French Camp <br /> STATE zip <br /> CA 95231 <br /> BOARD OF SUPERVISOR DISTRICT 0-1-3 LOCATION CODE KEY1 Kut <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> I -o Zo -6 ( <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE <br /> BUSINESS NAME ATTENTION:ORCARE OF (OPTIONAL) <br /> URS CorpGregory Korose <br /> MNUNGADDRESS PHONE <br /> 2870 Gateway Oaks Drive 916-679-2000 <br /> Cm <br /> Sacramento STATE ZP <br /> CA 95833 <br /> ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING® <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the mldersigned Applicant,certify that 1 am the Owner,Operaf r,Amhorized Agent'or Responsible Party and I aclmoWledge that RU PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this project will be baled to me at the address identified above as the ACCOUNTADDRESS for this site. 1 also certify that all <br /> Information provided on this application u true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQM COuSTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL Lars and REGULATIONS. As the undersigned Owner,Operator,Authorized Agent,or Responsible Pare•for the project located above under facility/site address.I <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQOPI COUNTY FjIj! iTA FIEALTH DEPARTME as soon as it is available <br /> and at the same time it u provided to me or my representative. J1 <br /> APPLICANT NAME(PLEASE PRINT) Andrew Archuleta SIGNATURE <br /> TITLE Field Manager TMID# 94-3077384 <br /> APPROVED BY I DATE ACCOUNTING OFFICE PRGcenawn COMPLETED BY DATE <br /> SITE MITIG ION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# <br /> ^— CHECK# RECEIVED BY WORK 'PE <br /> FEE: 2(T+ V <br />