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Unchanged since submitte dovernber 2012 <br /> San Joaquin County Environmental Health Department <br /> DATE 3 MASTER FILE RECORD INFORMATION"MSR" GREEN FORM <br /> O� SITE MITIGATION&LOP <br /> SNAD D><x SrOR EHDU ONLY OWNER IDt FCASES SRao(D(�qo UNIT IV <br /> OWNER FILE:COMPLETFTHEFOLLOWING PROPERTY OWNER IH�iwA770 1�L�G7WIACNEEcKiF OWNER CURRENT rotFILE iwmEHD E] <br /> PROPERTY OWNER NAME <br /> 4 (209)629-5070(Ask for Sam Franco) <br /> First M! Lasl PHONE NUMBER <br /> BUSINESSNAME E-MAILADDRESS ' <br /> 1-he Newark Group <br /> Owner Home Address <br /> i <br /> City STATE *!P <br /> I <br /> Owner MarllnQAddmas 2575 Grand Canal Blvd <br /> MallingAddress City Stockton sbte CA 7jp 95207 <br /> I <br /> CORPORATION Q INDMDUAL❑ PARTNERsHIP❑ FED AaENCY 0 OrKIM❑ <br /> SITE MITIGATION_ENVIRONMENTAL AiIiIIIIIEMENT VOLUNTARY CLEANUP_WATER QUALITY_iiW PIPELINE INVEs'TIGATION,�LOP <br /> FACILITY IDA INV! AccouNTID, A R 1100 AS <br /> ., PNONED EMKOYEE LEAD AaENcY:END_RWQCB_OTSC_EPA_ <br /> E.,1z7O� �(/�.. ' ,.Int-►may <br /> FACILITY FILE ComPLErE nyEFOLLOWING BUSINESS I FACILITY I SITE 1AMRfifAT10M- <br /> 15 this a NEW Business LGCAnON not previously regulated by the ENVIRONMENTAL HMTH DEPARTMENT? Yes ❑ No Q <br /> Is this an EXISTING Business LOCATION buts NEW TYPE of regulated Business? YES ❑ No <br /> BusmssfF'ACILIrYfSm NAME <br /> StTEAoDREss 800 West Church St ("Dopaco Area"only--see attachment) SLIITEN BUjswess PHONE i <br /> Com, STATEZiP <br /> �� <br /> Stockton 9520.1 <br /> BOARD OF StFPERVWA DISTRICT .� LOC.ATION CODE KEY4 KEV2 <br /> Mailing Address IfOIFFEREA7ftm F Adi r0M Admillon:orCare OF(0PtbfwQ <br /> Malling Address CRY STATE Zip <br /> SIC CODE APN f! r�(5 Z3 0 0 q �iDrolEtrr: <br /> THIRD PARTY BILLINSi INFO: Complete ff Billing Patty is different from Property owner or Facility operator identiTed above. <br /> BUSINESSNAME C— AS G A S Z n 1 C AflentiCn:GrC&re Of(000-9sfailFna Address 404 M A9JE—VIGTL4F,iN I VS_V L SIC) 3 to 3 5 702 <br /> c"Y KT N GSC`/ AU—:5> 4Q bE C ZIP 3o A 1,60 <br /> AccommrAOQHEBB far fees and charges OWNER FActuTYIBUSINESS THIRD PARTY BILLING <br /> RIE 1.1\t:\\p(_OgPI IA,\C'F ACK�rrN 1 Fn(t�tti�"r: f,the nndrnignc.l Applicyni,terrify thae 1 nm Ihr lhrrrrn Uprratur,or.tulln�ri:nlrQnmf of fir,Flu.inis."and F nrRnnw ledge that x11 PrM?11'1'f FS. <br /> PEYA7,F)LK Evl7+Rr'E:tTrdti'I CIE4ROU and/xr IIr.11'R1F(711AR(XV asso<iatcd,ith thin*Per"I;Ml will he billed tonic al the add ren identified 9h11-e a'Ihri11Y-01PATA1.1WECr for Iii+Rite. 1 o eerlifi(fiat <br /> all infQrrllaiinn provided on this npPliraiina is true and cornet:and that all mulaiell activities will lir performed in arrorllantt With A aPPlitabtr SiS,InAQlil\(;nl:\91'ONRIZAVC Cedes Andfor <br /> Standsrds and ti'IA'ff andfxr F'FDI'.R%I.Irws and Keguhliani AS Ihr 1111demift"W of%"iirr.operator,or ngtni of the ProPeThiocAled at tit Allxle fNCllitl'!!i1C alldTe.l hri�rbv`a01hoTIJe the 1 rIYLK of <br /> any and all results and environmental ac.e�inleDl informalion to S,IN JOAQUIN COUNTY ENV7RONMEN1'AI,11FAGI II I1 F:p�1 RT'A1I}\ , mon mil ic�lr pnd at Ihr lame time it is <br /> provided to ow or niv rtprrsrntANcr. <br /> APPLICANT NAME{PLEASEPR[NTl ��] of i ! ARL N�AU SlcNeruRE -r <br /> TITLE T'�".I # <br /> �! <br /> z7/ <br /> A oved By Data Accounting DtTco Prpeesatng Completed By Date � <br /> SITE MITICATIO AMO_UNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT CHECK* RECEIVED BY WORK <br /> PLAN PE - <br /> FEE:$ L�� <br /> J <br />