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San Jds"in County Environmental Health t„sillo"artment <br /> DATE f t)� MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADED AREAS FOR EHD USt ONLY OWNFwIDN CASE# }� �. /] UNIT IV <br /> OWNFIR FILE 1.COMPLETE THEFOUOWINGPROPERTY OWNER INFORmAnoN. u CNFO�NIFOWNER CuRREHTLrONRtEWITHEHO <br /> PROPERTY OWNER NAME <br /> First M! Last PHONE NUMBER <br /> BUSINESS E-MAILAME E-ML ADDRESS <br /> YAMADA BROTHERS <br /> Owner Nome Address <br /> 15406 Tracy Boulevard <br /> City STATE ZIP <br /> Stockton CA 95206 <br /> Owner Mailing Address <br /> same a above <br /> Mailing Address City State Zip <br /> CORPORATION® 'INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SiTE MmuATIDN ENvIRommemTAL AssESs11 Emir T VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINm INVE=QAT1ON LOP.? <br /> FACILITY ID# INV# AccouNT IO RO# i 3 q ; <br /> ld SS �% 0UO��o2b go 5Em <br /> r <br /> FACILITY FILE COMPLETE THEFOLcowNG BUSINESS I FACILITY I SITE INFORA/ATION. <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL.HEALTH DEPARTMENT? YES ❑ NO.® <br /> Is this an EXISTING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No <br /> BUSINE881FACtLrryla TE NAME <br /> YAMADA BROTHERS <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> 15406 Tracy Boulevard <br /> CITY STATE ZIP <br /> Stockton CA 95206 <br /> BOARD OF SuPERViSDR DISTRICT ,/5 LOCATION CODE 1 KEV1 KEY2 <br /> Mailing Address WDIFFERENrtSnm F✓acllftyAddress f Attentlali:orCare Of(optlawl) <br /> Mailing Address City STATE ZIP <br /> SiC CODE APN# COMMEIt'f: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFacllity Operator identified above. <br /> BUSINESS NAME _ - Attention:orCare Of (optfonag <br /> Advanced GeoEnvironmental 'Inc. <br /> Mailing Address PHONE <br /> 837 Shaw Road 800-511-9300 <br /> Cm STATE LP <br /> Stockton -CA 95215 <br /> for fees and charges OWNER FAcILrNIBUSiNEssMMOWN <br /> HrRD PARTY BILLIN <br /> BILLING AND Co=ANcB AckNowLRpGmcmri 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Rminecs,and I acknowledge that all PERWT FEES, <br /> PENALTfEs,EAroRcufENTCH4RGes and/orKOURLYCHARGES associated With"operation will be billed to me at the address Identified above as the ACCOrJNTADDRE55 for this site, I also certify that all <br /> information provided on this applleation 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 facilltyislte 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 av aisle and at the same time it is <br /> provided to me or my representative- <br /> APPLICANT NAME(PLEASE PRINT) Ally Colavlta SIGNATURE <br /> TITLE TAX ID <br /> Project Scientist, 68-0354606 d <br /> Approved 13y Do" Accounting t]Nlos Processing Completed By Onto <br /> SITEMT'I6ATIDN AMOUNT PAID DATE OF P►YMRlrT PAYMENT TYPE RECEIPT# CHECIt# RECEIVED BY 71VORk Pt�te{• - <br /> FEE: r <br />