SITE INFORMATION AND CORRESPONDENCE

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t� San J auin County Environmental Health ')artment DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM ^� rr I \ t�SgE MITIGATION & LOP SHADEjAREAS FOR H USE ONLY OWNER IDA CASE A -r / V UNIT IV OWNER FILE:COMPLETE THE FOLLOWING PROPERTY OWNER INFORMA T/ON: S ? /F OWNER CURRENTLY ON FILE WITH EHD PROPERTY OWNER NAME Edna Moore Ny1 (20P - 639,k2 First M/ last PHONE Nu BUSINESS NAME Property Terminals Inc. E L� Owner Home Address PO Box 8307 1 T'� City �, � � �• STATE ZIP Stockton ,� CA 95208 Owner Mailing Address " Mailing Address City fflkTIS�avrC� State Zip Nw CORPORATION Ex INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ SITE MITIGATION ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP FACILITY ID# INV# ACCOUNT ID PR V RO N a �V�L] L w 3 n ;�+ J`}t�l• I �. tk`41 .,� b FACILITY FILE COMPLETETHEFOLLOWING BUSINESS If FACILITY/SITE INFORMATION: Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ® MW Destructn Is this an ExIST1NG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No X BUSINESs/FACILITY/SITENAME Former Moore Truck Lines SITE ADDRESS 3400 Newton Road SUITE# BUSINESS PHONE CITY Stockton STATECq zIP 95215 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEYZ Mailing Address ifD/FFERENTbvm Facility Address Attention:or Care Of(optional) Mailing Address City STATE ZIP SIC CODE lfftf/E C) �p COMMENT: THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. BUSINESS NAME Advanced GeoEnvironmental Attention:or Care Of (optional) MailingAddress 837 Shaw Road PHONE 800 511 9300 CITY Stockton STATE CA zP 95215 AccoumTAoafor fees and charges OWNER FACILITY/BUSINESS TkItID PARTY BILLING XXX BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERmIT FEES, PENALT/ES,ENFORCEMENT CnARGES and/or HouRLYCHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRESS for this site. I also certify that 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 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 any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. '/'_-' APPLICANT NAME(PLEASE PRINT) William Little SIGNATURE U o��'�'� TITLE Geolgoist TAX ID# Approved By Date Accounting Office Processing Completed By Date; =�tlj' L $ITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY 1'431;4-ka4PE' FEE: