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f - SAN JOT.. °IN COUNTY ENViRONMENTAL.HEALTH DI `ATMENT D ' "MFR" Emu IDA 9/21/201. MASTER FILE RECORD INFORMATION oP SITEShffiUrIZ �L - 1 1 AA�� TT 1'I If1� nT�E�ALTH CASE# + DE s D OWxER ID# f N r m �� , CirRvl i f -i.uT .•,.4. ��'',,.. ',�.,r. {* .F.,. + 'I W,.. Y i�. FS ` OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION. �HFcxrFowrveRrs HD❑ PROPERTY OWNER NAME Michael Contreras (909) 885-5953 - FIRST M! LAST PHOWE NUM13ER 7-7 - £-MAIL ADDRESS BUSINESS NAME Wickedf low, LLC. OWNER HOME ADDRESS 1500 N Shaw Road Cllr Stockton STATE CA zP 95215 OWNER MAILING ADDRESS MAILING ADDRESS CITY STATE ZIP , ®CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENTAGENCY. ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP—WATER QUALITY HW PIPELINE INVESTIGATION_LOP X FACILITY ID# , IHV# ACbOUN7 ID ' - PR#1 ROS# y,+ ASSIGNED EMPLOYEE LEAD AGENCY EHD_�iWCICB DISC EPA , -4T i FACILITY FILE:COMPLETE BUSINESS 1 SITE!PROJECT INFORMATION:y ❑ MENTAL HEALTH DEPARTMENT? YEs E] No IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRON IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE�OF WORK? YES ❑ No ❑ BUSINESSIFACILITYISITOPROJECTNAME FORMER CANTEEN CORPORATION SITE ADDRESS IPROJECT LOCATION1500 N Shaw Road' - SUITE# BUSINESS PHONE CITY Stockton STATECA zip 95205 .D o - - ti �r3 I I KEY1n, r CODE y- ��} s Pskr;, 't;h;#� ;5 ,W * ' ''�-�•5� ,' A. ,i�p.T�i rr,�.-rr r SOARDOFSUPERVISCRDISTRICT ,� LOCATID `a r, LL' - MAILING ADDRESS.IF DIFFERENT FROM FACturY ADDRESS ATTENTION:ORCARE Of(QPTIONAI.f 2400* Yorkmont Road Marty Scannell MAILING ADDRESS CITY - Charlotte STATE NC ZIP 28217 'COMMENT J 11 SICCODE 4i y,: 'APN# THIRD PARTYBILLINGINFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME Alitea USA, Inc. ArtEN'TION:t7RCAREOF(orrroxAtl Patrick Mart MAILING ADORES9g PHONE 9009 Mountain. Rid e �Drive, Ste . 110 (512) 342-9468 sTaTeTX ZIP 7 8 7 5 9 CITY Austin ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITYIBUSINESS❑ THIRD PARTY BILLING® BILLING AND COMPLIANCE ACKNOWLEDGMENT'. I,the undersigned Appticant,certify that I am the Owner,Operator,Aldflorized Agent,or Resporuible Party and I acimowledge that all PERMlT FEES. PENALTIES,ENFORCEMENTCmARGER and/or HOURLY CHARGES associated with this project will be billed to me at the address identified above as the ACCOUNTA➢DRESS 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 andlor STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS.1 As the undersigned Owner,Opereior,Authorized Agent,or Responsible Purdy for the project located above under facility/site address,i hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIR AL ALTH DEPAR mENT'as soon as it is available sad at the same time it is provided to me or my representative. APPLICANT NAME(PLEASE PRINT) Patrick Marty SIGNATURE TITLE Project Professional TAXID# - APPROVED BY DATE ACCOUNTiNO OFFICE PROCESSING COMPLETED BY DATE ` PI- ' RECEIPT# r CHECK# 'RECEIVED BY WORK PLAN PE M StrE MrrIGATION AMOUNT PAID�� DATE OF PAYMEtIT _ PAYMENT TYPE i' _ J5 i s ru r� I,� w N FEE. F• 1� J