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San Jo 6111in County Environmental Health Cortment GREENFORM <br /> DATE M f <br /> STER FILE RECORD INFORMATION MFR SITE MITIGATION &LOP <br /> SHADED ARE REMDU EO Y OWNEI 10# <br /> CAME UNIT IV <br /> OWNBRFILE:COMPLETE THEFOLLOH7 PROPERTY OWNER INFORMATION: <br /> CNECXIF OWNER CURRENTLyoNFltew/TN END <br /> PROPERTY OWNER NAME Gaut (209) 466-4601 <br /> Gregory&Paulette <br /> First MI Last PHONE NUMBER <br /> EMAIL ADDRESS <br /> BUSINESS NAME <br /> NA <br /> Owner Home Address <br /> 1607 Turnpike Road <br /> STATE LP <br /> C11 ty CA 95206 <br /> Stockton <br /> Owner Malting Addreas <br /> as above <br /> Smee L'p <br /> Mailing Address City <br /> CORPORATION❑ INDIVIDUAL <br /> PARTNERSHIP FED AGENCY 11 OTHER❑ <br /> ENVIRONMENTAL ASSES MENTVOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP x <br /> SITE MITIGATION_ �4y <br /> FAcam ID# INVlI <br /> AceouNID PRMRO# Ile' uE"�"vtoifE <br /> A k <br /> FACILITYMLE COMPLETE THE FOLLOP INGBUSINESS/FACILITY ISITE INFORMATIOW <br /> IS this a NEW Business LOCATION not preVIOU Ily regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ <br /> No <br /> IS g1L4 an EXISTING BUSIneSS LOCATION but B EW TYPE of regulated BUSInaSS? <br /> YES ❑ No KI <br /> BUSINESSIFACHATYSnE NAME Comfort Air <br /> SURE# BUSINESS PHONE <br /> SITE ADDRESS <br /> 1607 Turnpike R Dad STATE LP <br /> cm CA 95206 <br /> Stockton <br /> BOARD OF SUPEIMSOR DISTRICT <br /> nos CODE REY1 HU2 <br /> Mailing Address ifDIFFEREHrtrom FaGi#tyAdd s <br /> Attention:or Care Of(optional) <br /> STATE LP <br /> Mailing Address City <br /> SICCDOE APN# CO m: <br /> tor <br /> THIRD PARTY BILLING 1NFOI Complete Billing Party is different from Properly Own Attention:orC re Offirot-FaClIKYOPISd( oma)identified above. <br /> BUSINESS NAME <br /> Adv need Gel me ital Inc. PHONE <br /> Mailing Addreas 800-511-9300 <br /> 837 Shaw Road STATE zip <br /> CITY CA 95215 <br /> Stockton <br /> AcdouHrADnR[,8#for fees and charges <br /> OWNER FACILITY/BUSINESS HIRD PARTY BILLIN <br /> Rod I acknowled a that all PeRartT Fees, <br /> BILLING AND COWM6&,E ACKROwLEDONENT: L the resigned Appaeant,certify that I am DN Owner,OPermarq Or <br /> Authorized Agent of this Bodeen, R <br /> PENALTIES,ENFORCEaIENT CNAR6PS and/or HOURLYCHAF associated with Ws operation will be billed to me at the address Identified above at theACrne ADDRESS(or Itis site. 1 also certify that all <br /> information provided on thin application is true and ror et;and that etI regulated ae6vidn cc <br /> will be performed in aordance MINI all applicable SAn JOAQUIN CDurvry Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Lam and Regula i ns. As the undenigned awns;operator,or agent of the property located at the shove fulIty/she address,1 hereby autiwriu the release or <br /> any and all roolls and environmental Internment inform don m SAN JOAQUIN COUNTY ENVIRONMENTISIGLNA�RE <br /> DEPARTMENTrn coon l tlse same date([is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT <br /> Ally Colav a <br /> TAX ID# <br /> 68-0354606 <br /> TITLE Project Scentist <br /> Accounting Office Proeeeam,Completed By Dale <br /> proved By DEV ,. <br /> SITE MITIGATION AMOUNT PAID DATE Of PAYMENT PAYMENT TYPE <br /> RECEIPTS CHECK RECENED BY WORK PUMP ` <br /> FEE:; <br />