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San J 4uin County Environmental Health . ,)artment <br /> DATEMASTER FILE RECORD INFORMATION "MFR" mrr GREENFORM <br /> 1/ :2- <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHED USE ONLY OWNER ID# O U R I CASE# 5 V C) Z7� UNIT IV <br /> OWNER FIL :COMPLETE THE FOLLOW/NG PROPERTY OWNER/NFORMA TION.- CHECK/F OWNER CURRENTLYONF/LEW/TH EHD <br /> PROPERTY OWNER NAME Donald L Roek �09 610-8344 <br /> First Ml Last PHONE NUMBER <br /> BUSINEss NAME E-MAIL ADDRESS <br /> Owner Home Address <br /> City STATE zip <br /> Owner Mailing Address <br /> P.O. Box 30038 <br /> Mailing Address City State Zlp <br /> Stockton CA 95213 <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP IX FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL AssESSMENT_VOLUNTARY CLr-ANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> FACILITY ID# ][: INV# ACCOUNT ID jPR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB_DTSC_EPA <br /> 21 I (,D 3,3 1,- 7 pS��$'1�f /6?` <br /> FACILITY FILE COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No X <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No �I <br /> BUSIN SS/FAp ILITY/SITE NAME <br /> OeK Construction Iso v <br /> SITEADDRESS SUITE# BUSINESS PHONE <br /> 3736 HiqhwaV 99 <br /> CITY STATE ZIP <br /> Stockton CA 95215 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address KD/FFERENThvIn Fac!/KyAddress Attention:orCare Of(opNona/J <br /> Mailing Address City STATE ZIP <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of (option/J <br /> Advanced GeoEnvironmental Inc. <br /> Mailing Address PHONE <br /> 837 Shaw Road 209 467-1006 <br /> CITY <br /> TMStockton STATE ZIP <br /> A 95215 <br /> Accou�--ultrAonREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERMIT FEES, <br /> PENAL7IEs,ENFORCEMENTCffAR(:Es and/or HOUR/.P CHARGES associated with this operation will be billed tome at the address identified above as the ACCOUNTADORESS for this site. 1 also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM as soo s it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) Robert E. Marty SIGNATURE <br /> TITLE TAX ID# <br /> President / <br /> Approved By Date Accounting Office Processing Completed By Date / L- <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED Y WORK PLAN PE <br /> FEE:$3/� X375 2�3�I L �4q� �SD <br />