Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE 8/8/13 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION <br /> ,&//LOP <br /> SHADED AREAS FORE HD USE ONLY OWNER IO# 0 W 1 i1 I�: � CASE# UNIT ' r <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: ONECKIF OWNER tS CURRENTLY ON FILE Iv/TN END <br /> PROPERTY OWNER NAME JamesBeall 21.10 <br /> FrPSr M! LAST PHONENUMBER <br /> BUSINESS NAME St Johns Corp,DBA in CA as Columbia River Corp E-tMIL AOgREss <br /> 'ebru�st'ohnscor .corn <br /> OWNER HOME ADDRESS <br /> CITY STATE LP <br /> OWNER MAILING ADDRESS <br /> PO Box 17095 <br /> MAWNGADDRESSCITY Portland STATE ZIP 97217 <br /> Q CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT Y VOLUNTARY CLEANUP WATER QUALITY_HVY PIPELNE INVESTIGATION LOP_ <br /> FACILITY ID# <br /> 1EINV# ACCOUNTIO RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_ RWCtCB_DTSC_EPA_ <br /> X190 03 88 5 0553793 Doti MK y <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED 13YTHE ENVIRONMENTAL HEALTH DEPARTMENT? YES M No ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES M NO ❑ <br /> BUSINESS/FACILITY/SITE/PROJECT NAME <br /> Moffat BoulevardMTatts E ui nient <br /> SITE ADDRESS/PROJECT LOCATION 1813 Moffat Boulevard SUITE# BUSINESS PHONE <br /> CITY Manteca STATE ZIP 95336 <br /> 1[8:.:A.:..FSUPERVISOR DISTRICT LOCATIONCODE KEY1 KEYZ <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:OR CARE OF(OPTIONAL) <br /> PO Box 17095 <br /> MAILING ADDRESS CITY STATE zip <br /> Portland OR 97217 <br /> Sri <br /> FN9AP COMMENT: <br /> a - <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ATTENTION:OR CARE OF(OPTIONAL) <br /> MAILING ADDRESS PHONE <br /> CITY STATE ZIP <br /> ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNERM FAMLITYIBUSINESS❑ THIRD PARTY BILLING❑ <br /> Blt.t.l9(.ASU C(U1Fi.l.t\('E r\C1:90tYt.F.DC\IF.ST: f,the undersigned Applicant,certify that tam the Ouvtcr>Operalnr,.dntlmti,-.ed.tgeab a•Re.%ponsible Parry and I acknnaiedge that all PravtTFca. <br /> PEIIILTirs,F,.%F0Rccvc,x rC'rt IRGLs and/or KOt RLI'CN.IRGES associa(ed wish this project will be bifled to me at the address identified above as the ACCOf ArADDRcu fur this site. I also certify that ail <br /> information provided on this application is true and correct;and that all regulated activities hill be performed in accordance with all applicable Sav J0AQUIv COUN711 ORDI%,nNcE CODES and/or <br /> ST1NDARDS attd STATE an[I/OP l'EOCR�t I.Lntts and Aetx'Lrt'IOss. As the undersigned Owner.Uprrnror..arrrhnriced:tgenr,or Reapansib/e Par•!-for the project located nbove under facility/site nddress.I <br /> hereby authorize the release or any and 1111 results,reports,and other environmental assessment information to S.at.fo.toti.,O u\Tt'E.,1VIRONAIENTAL IIF-\LTH DFRU TMEST as$00-1 as it is available <br /> and at the same('ime it is provided to nic or rm•representative. i <br /> Tunes Beall , <br /> APPLICANT NAME(PLEASE PRINT) I SIGNATURE <br /> TITLE til ��� '�1 ,t i 7AXID# C{ ` cj l 1 D-- <br /> DATE <br /> 1 <br /> APPROVED 0Y "'C' (� `-D'ATIE•q-._-- ACCOUNTING OFFICE PROCESSING COMPLETED BY/ ` tBY <br /> "`�-t-o��:.� <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT RECEIPT# CHECK# FRECEIVEDWOR PL�AN PEFEE:$ ULkO1� <br />