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San Joaquin County Environmental Health Department <br /> GATE LL1,MASTER FILE RECORD INFORMATION EMFRda GREENFORM <br /> SITE MITIGATION& LOP <br /> SHWrNER 100 CARE# UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOW/NG PROPERIYOWNER INFORMAT/ON.' CHEOMP OWNER 40MREnnroxFILEHOW END L) <br /> PaOPmrvoWNER NANE Manuel Toledo (209943-1777 office <br /> First MI Last PHONE Nueses 209.614.0063 cell <br /> BDSINE9e NANE C & R International Sales, Inc s4t.EAO <br /> manuelCcDcandrinternational.com <br /> Owner Home Address <br /> city STATE ZIP <br /> Owner Mailing Address 2403 Navy Drive <br /> Malling Addreas City Stockton Bite CA Zip 95206 <br /> CORPDMno"171I INOWIDUAI❑ LI <br /> PARfNERSHIIPP❑ FEDAoENcY❑ OTHER❑ <br /> ItSITE MITIGATION ENVIRONMENTAL ASSESSMENT!VOLUNTARY CLEANUPLam.WATER QUALITY OHW PIPELINE INVEWIGATION❑ LOP A <br /> FACILITY IDS INva AccouwlD PRMIROR ARRIGNEO EMPLOYEE LEAD AGENCY:EMD ✓ RWOCB DTSC EPA <br /> FAGILITYFILE COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YEs ❑ No <br /> Is this an EXISTING Business LOCATION but a NEWTYPE of regulated Business? YEs ❑ No 91 <br /> BumbegeIFAciuryISfIE NAME C & R International Sales, Inc. <br /> SneADOREaasDIBUBINEaePHOE24O3 NavyDrive <br /> 209.943.1777 <br /> Dg Stockton STATE 95206 <br /> BOARDOFSUPERVISORDismucT LOCATX1NCOce KEY? KEY2 <br /> Malling Addreas/IOIFFERENTf m,Fac/1RyAddress Attention:orCare Ol(optionel) <br /> Meiling Address City STATE 21P <br /> SIC CODE 71 APNR COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orPacility,Operator identiRedabove. <br /> BUSINESS NAME Cardno ATC Attention:arCare Of(opHoneq <br /> MallingAddreee 1117 Lone Palm Avenue, Suite 201 B PHONE(209) 579.2221 <br /> CarrTE ZIP <br /> Modesto CA 95351 <br /> AOCOJIRrAOOREST for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING Atm CONIPI.IAN(T ACK"WI,VUGaIENT: 1,We undersigned Applicant,certify Ihat 1 am the Ouner,Operator,or Aa9aNud Agent of this Business,and I acknowledge that all PEAUnFEES,, <br /> PE LnET,ExroACE%1&vTC11As,,,UamVor NWa[I'C11,actiossocinied with this operation will be billet to me at the address Identified above as flocAl Do.YrAnoaEs for this site, faisa certify that <br /> all information provided on this Application is true and correct;sad that oil regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Coda and/or <br /> Sta ndaNs and STATE and/or FmrRAL Lawn and Regulations.As the undersigned owner,operator,or agent of the properly located at the above frcility/aite address,l hereby mitharice the release of <br /> any and all results gait em,iroamen mi nssasmrnt inf nnaidi n to SAN JOAQUIN COUNTY EINVIRONNIENTAL HE.ALT11 EPARTNIENT as soon as it`is�available and at the mme time it is <br /> provided to m e or my represenmtive. / I T, "'C <br /> APPLICANT NAME(PLEASE PRINT) MI hael Sonke SIGNATURE .WTI L <br /> TITLE Project Manager ,e TAX ID a 460399408 <br /> FFA�imawhl1 Dole AinsamUnti0fil.tifircamumbeConputhailly Dole <br /> SRE MRIMTION ANOUHr PAID DATEOFPAYMENT PAYMENTTYPE RECEIPTR CHECK# RECEIVED BY WORN PLAN PE <br /> FEE:; <br />