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San J Din County Environmental Health D1rtment GREEN FORM <br /> DATE M STER FILE RECORD INFORMATION MFR SITE MITIGATION & LOP <br /> 3E M FOR EHUU 98LY OWNE ID# <br /> CASE UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOWIN PROPERTY OWNERINFORMATION. <br /> CNECN IOWNER Cl/RRENTLYON FILE WITN EHD <br /> F <br /> PROPERTYOWNERNAMEGaut (209 466-4601 <br /> Gregory&Paulette <br /> Frst <br /> MI Last PHONE NUMBER <br /> E•WUL AODNFJis <br /> BUSINESS NAME <br /> NA <br /> Owner Home Address <br /> 1607 Turnpike Road —_._—_ <br /> STATE LP <br /> city CA 95206 <br /> Stockton <br /> owner Mailing Address <br /> same as above <br /> State Zip <br /> Meiling Address City <br /> CORPORATION❑ INDIVIDUAL <br /> PMTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL Ass ENT_VOLUNTARY CLEANUP_WATER QUALITY__HW PIPELINE INVESTIGATION_LOP x <br /> Acceu ID 4MMRO# ,y� ` a <br /> FACILITY ID# INV# C ���� �,k ( � .M Idg t M S viii 5 <br /> .z..A�L1v.. rte% <br /> FACILITY FILE COMPLETE THEFOLLO NO 13USINESSI FACILITY/SITE INFORMATION. <br /> Is this a NEW Business LOGAnON not previou regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> IS this an EXISTING Business LOCATION but a P EIN TYPE OT regulated Business? <br /> YES ❑ No Ej <br /> BUsINessIFACNTTISITENAME Comfort Air <br /> BUITE# BUSINESS PHONE <br /> SDEADORESS <br /> 1607 Turnpike R ad <br /> STATE LP <br /> CITY CA 95206 <br /> Stockton <br /> BOARD OF SUPERVISOR DAtTRIGT L ON CODE <br /> KEPT KEr2 <br /> Attention:or-Care,Of(OPN➢naI) <br /> Mailing Address irDIFFERENTirom Fircilityalchdra Is <br /> STATE LP <br /> Mailing Address City <br /> SIC CODE APN IS COMMENT: <br /> THIRY PARTY BILLING INFO: Complete to Billing Party is different tram Property Owner Orr Cotlty O til at od)r intifiedabove. <br /> AttentionBUSINESS NAME <br /> Advanced GeoEnvironmei talkInc. PHONE <br /> Mailing Address 800-511-9300 <br /> 837 Shaw Road <br /> STATE LP <br /> Cm CA 95215 <br /> Stockton <br /> AFCpyREelihaRE T for fees and charges OWNER FACILITYIBUSiNESS HIRD PARTY BILLIN <br /> BILLING AND COWLIANC ACKNOWLEDGMENT: 1,the or eoigned Applicant;certify that I am de,Owner,Opemtoq or Authorized Agent of INS Business,and I aclmowledge(hat all PERMIT FEES, <br /> P£NALTZES,ENFORCEMENT CHARGES and/or HOURLY CHARG -am`.ted with Ws upsEmm.will be billed to rile el the address Identified above as the ACLOUMADORE55 for this site. I also certify that all <br /> information provided on this application is true and carr t;and that all regubl"acfivifics Wili be performed in accordance skids all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> undersigned owner,operator,or agent of the Property <br /> Kaded <br /> e above <br /> any <br /> Standards <br /> roa is and enviro rental ass or FEDEAAS- umeutand ainfforrna'on m gulltic or- As SAN JOAQU N COUNTY ENVIRONMENTAL HEALTH DEPART 4ENTf3,sm.a tr ay avail ld hereby <br /> d at thersame timerelease <br /> it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) Ally Colavi SIGNANRE A/ <br /> TAX ID# <br /> TITLE Project Sci Intist 68-0354606 <br /> AccouMhg Offlo.procasing Completed By Data ppProved 9Y Data \\ 2 . <br /> RECEIPT ONE CK# RECEWED aY NO11, <br /> SITE MITIGATION AMOUNT PAID <br /> MMOUNNTPAID DATE OF AYMENT PAYMENT TYPE <br /> FEE:S / VVI \\� Z - � V 31982 V •1'\. <br />