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San Joaquin County Environmental Health Uepartment DATE 04/14/2015 MASTER FILE RECORD INFORMATION"MFR" GREENFORM Q SITE MITIGATION& LOP SHADED AREAS FOR EHD USE ONLY I OWNER ID# Okf od2oSs-6 CASE#SR�T `l(oS UNIT IV OWNER PILE:COMPLETE THEFOLLOW(NGPROPERTY OWNER&FORMAT/ON. CHECK/F OWNER CURRENTLYONFILEW?H EHD PROPERTY OWNER NAME Miller = Trust / 209\ 474-2560 First MI Lest `PHONE/NUMBER BUSINESS NAME E-MAIL ADDRESS Miller Trust Property N/A Owner Home Address 3031 West March Lane city STATE ZIP Stockton CA 95219 Owner Mailing Address Same as above Mailing Address City state LP CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER x❑ SITE MITIGATION ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HIW PIPELINE INVESTIGATION_LOP FACILITY ID# INV# ACCOUNTID PRNRO# ASSIGNED EMPLOYEE LEAD AGENCY:EHO_RWQCB_DTSC_EPA _ gn�z2-97(, ��Atcz)o'*j IF -PA06-1002b FACILITY PILE COMPLETETHEFOLLOW(NG BUSINESS/FACILITY/SITE/NFORMAwAf.' IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES El No ❑ IS this all EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No x❑ BUSINESS/FACILITY/SITE NAME Miller Trust Property SITE ADDRESS 6025-6049 SUITE# BUSINESSPHONE CITY STATE LP Stockton CA 95207 BOARD OF SUPERVISOR DISTRICT 02 LOCATION CODE (0/ KEY1 KEY2 Mailing Address ifD/FFERENTfrom FaciiityAddress Attention:orCare Of(optional) 3031 West March Lane Mr. James Morris Mailing Address City STATE ZIP Stockton CA 95219 SIOCODE APN# COMMENT: o ,Y y -dro THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. BUSINESS NAME Attention:orCare Of(opNonaQ Advanced GeoEnvironemental Inc. Robert Marty Mailing Address PHONE 937 Shaw Road 209-467-1006 CITY STATE ZIP Stockton CA 95215 ACCDUNTADDREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owtter,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be bilked tome 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 properly located at the above facility/site address,l hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT assd at the same time it is provided to me or my representative. APPLICANT NAME(PLEASE PRINT) Robert Marty SIGNATURE { / TITLE President TAX ID L Approved By I Date Accounting Office Processing Completed By Date SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE FEE:$3?0 3�o y•t5.t s (>- K Y,t,5,f eOzwgk a.4 T<)