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_ San J'aquin County Environmental Health Apartment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED ARLATFQkFHD WE ONLY ItOmER IDF CAS!• UNIT IV <br /> OWNER FILE:CO/WLETEPROPER1YOWNERIRESPONSIBLEPARTY/Amilim nom C-CKIF OWNER CMMNnyo rmwwirNEH , J <br /> PROPER,Y OIvxER NNME Steward Sobek _ (415) 617-5791 _. _.A <br /> FISP I Lau PHONE NUMBER <br /> BMWEss NAME Stuart Limited Partnership E."AADOREss <br /> Owner Home Addrea <br /> Gly STAN ZIP <br /> Owner Mailing Address P.O. Box 370055 <br /> Maiii"Address City Las Vegas S'a'e NV >aP 89137 <br /> ❑CORPORATION 0INOIWOUAL til PARTNERSHIP ❑GOVERNMENT AGENCY El RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION _ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY HW PIPELINE INVESTIGATION_LOP_ <br /> FAOLITY IDs IINVF Accouxr lD PII SROs AausNEBEwLOYEE Luo AolxCr:END. RWQCB_OTr1C—EPA <br /> _ <br /> �1001201>1; ARcot`tara8 �sfSo3o AJoHNA"l <br /> FACILITY FILE: Comptm BUSINESS/SITE/PROJECT lAtFoRmwvow <br /> Is this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ® NO ❑ <br /> IS this an EXISTING Project LOCATION but a NEW SCOPE OF WORK? Yes ❑ NO to <br /> BUSNESSMACI I /SITEIPRO.ECTNME Quality Cleaners,Tracy Corners Shopping Center <br /> SITEADDRESSIPROJECTLOOATIOM SUITE SLIMNESS PHONE <br /> 3081 North Tracy Boulevard <br /> Cm STATE ZIP <br /> Tracy CA 95376 <br /> BOARD OF SUPERVISOR DISTRICT S LOCATION CODE KEY1 K-2 <br /> Mailing Address ifDIFFERENT/row,faacMYyAddiwas Atterdlon:o Cars Of(Irpeonw) <br /> Mailing Address City STATE Zip <br /> SIC CODE APNE COMMENT: <br /> 2fY-1 6- <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orResponsible Party identiried above. <br /> BUSINESS NAME AOeneon:orCare Of /CplaW)Ton1Cam bell <br /> Partner Engineering and Science, Inc. P <br /> Mailing Address 2154 Torrance Boulevard, Suite 200 vNOME 508-876-2660 <br /> CITY Torrance STATE 90501 <br /> ADCODRrAWRM for fees and Chergae OWNER FAciurrBUSINESS THIRDPARTYBILuNG <br /> B o(- T .r AL N.l)r. clll Mf.'T: L RIM,mdflYRmd %,pIN.wL r,rlif.111aI I.m RIM(Mea'/.IIIMrA._IAM.�JR , B p—mlf Pum'and I.&FAAAkdee Ix.I aD ft.NII IFFY. <br /> Pt.'U Uel.E111IA(Fill II CIIAeot I anP.r IIUI IIII niAr.[+A,aariaMd sid,din pm(en xd1 IM bdkd H.nM At dD addm identified Acme a dM+,..,(.IIN.EN For dlu,,I. I.IwrenifT Ib.I dl <br /> information proTillyd on Ibk aP,dkonom a Irw And rmFA,C AM Ibm.11 relolnred.,h61x,rill In perbMmrd in.rrmd.me nidi AN nPpik.bk W%AI]OI IA f(X NTT DnlinanrA(a10 ndfor <br /> Swd.rdx anti Stn R xmPAr FFDFRM IAxe and RReblNxn Ac Ournnd""Irwed 4m_'.(11Mramr,ludarveJ %,.,.or Req..xiblr P.ry rnr INF Prryerl bnlNl ahnre older Iaihi%hiN Mdre..,I <br /> Nrreb adwrur RIM rekaM ohm and dl mnulb,nlwro.AmA1 dhrr m.irwmmndai aaYAawMnN inl.,nia.Lr 1\\J(1 MA 1%(01 NTN I.V\IR0M1FNTAL NE%I I II DF PART%IFN 1.—A, <br /> :.R.ailaNe nld anhe.amrmmlr i.pmdded mmror <br /> APPLICANT NAME(PLEweE PRINT) Tom Campbell SIGNATURE - j - /k <br /> TITLE TAxIDB 20-8264379 <br /> TItC <br /> ProjLct 14anager <br /> Ap;.o.d_BY _DOL _ _ 4ccouMilg OHlu Pracaanrg Compbled_BY _ CA. <br /> -- PAYMENT TYPE I__—_--- --� <br /> SITE MITIGATION AMOUNT PAW I DATE OF PAYMENT RELEIPT0 CHECKS <br /> REcrrveD ar <br /> WORK PIAN PE <br /> FEES 1550 a <br />