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San J luin County Environmental Health )artment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> �7 ` t�WE MITIGATION &LOP <br /> SHADED AREAS FOR EHD USE ONL`j OWNER IDS CASE# //w Lr / \1` UNIT IV <br /> Is"t��CJ,Y\ <br /> OWNER FILE:COMPLETETHEFOLLOW/NG PROPERTY OWNER INFORMA77oN.- S IF OWNER;CuaRENTLyoArF1LEWITH EHD <br /> PROPERTY OWNER NAME Edna Moore 0'- 2,0$~ 639 -'jX 2 <br /> First Ml Last PHONE NU <br /> BUSINESS NAME Property Terminals Inc. E Ll� <br /> Owner Home Address PO Box 8307 1 <br /> City t ... STATE ZIP <br /> Stockton y 1,1 �_ CA 95208 <br /> Owner Mailing Address �A <br /> Mailing Address City <br /> � ZiSERv�G� State Zip <br /> CORPORATION IN INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INvESTIGATION_LOP <br /> FACILITY <br /> ON INV# AccouNT ID PR#/RO# ! Pto <br /> I <br /> N"� <br /> FACILITY FILE COMPLETE THE FOLLOWING BUSI NESS I FACILITY/SITE INFORMATION: <br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NOR MW Destructn <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No M <br /> BUSINESsiFACILITYISITENAME Former Moore Truck Lines <br /> SITE ADDRESS 3400 Newton Road SUITE# BUSINESS PHONE <br /> CITY Stockton sTATECA z,P 95215 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE / KEY1 KEY2 <br /> Mailing Address IfO1FFERENT lrorrt FacilityAddrless I� Attention:or Care Of(optional) <br /> Mailing Address City STATE LP <br /> SIC CODE APN#I COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identiried above. <br /> BUSINESS NAME Advanced GeoEnviro n mental Attention:orCare Of (optional) <br /> Mailing Address 837 Shaw Road PHONE 800 511 9300 <br /> CITY Stockton STATE CA zP 95215 <br /> 771 AggayAtrADgwss for fees and charges OWNERFACILITY/BUSINESS T D PARTY BILLIN XX <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT C11IRGES and/or iIOURLYCHARGEs associated with this operation will be billed to me at the address Identified above as the ACCOUNrADDRESS for this site. I also certify that all <br /> 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 DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. _ <br /> APPLICANT NAME(PLEASE PRINT) William Little SIGNATURE <br /> TITLE Geolgoist Tax ID# <br /> Approved By Date Accounting force Processing Completed By Date <br /> SITE MITIGATION AMOUNT PAIDDATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY 'WORN Pl:isNP r <br /> FEE: <br />