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San .1ddi;(uin County Environmental Health department <br /> « " GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION SFR <br /> 11 3-31- 0 � I SITE UNIT <br /> &LOP <br /> V.VSHADED AREAS FOR EHD USE ONLY OWNER ID# �CA.E# IT <br /> O1MERFILE:COMPLETETHEFOLLOW/NG PROPERTY OWNER/NFORMA77om CHEcxtFOWNER CURRENrLYONRLEN7rHEHO <br /> PROPERTY OWNER NAME �1_ �„ �T`,e r f7 ,a `2'0 2 00 <br /> P� First MI Last PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> former HARRY'S AUTO <br /> Owner Home Address <br /> PO BOX 757 <br /> City ® .4 STATE ZIP <br /> LODI ��O 1 CA 195241 <br /> Owner Mailing Address <br /> same as above <br /> (� �1 <br /> Mailing Address City State Zip <br /> CORPORATION❑ INDIVIDUAL® PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE 114meATION_ErmRONESENTAL AssESSMENT_VOW CLEANUP_WATER QUALITY_ _HW PIPELINE INVESTIGATION_LOP X <br /> FACILITY ID# INV# AccouNT ID PRRO# ` + h�"kt'T `D <br /> tcl�f~ri� <br /> R' a03' 3 t ` SIM-11' <br /> F g <br /> FACILITY FILE COMPLETETHEFOLLOWiNG BUSINESS/FACI ITYISITE /NFORMAT(ON: <br /> Is this a NEW Business LOCATION not previously regulated by the ENvIRONMENTAL HEA TH DEPARTMENT? YES ❑ No El <br /> IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO El <br /> BUSINESS/FACILITY/SITE NAME <br /> former HARRY'S AUTO <br /> SITE ADDRESS V A SUITE# BUSINESS PHONE 17-91 <br /> 2662 N.Wilson Way Cm STATE ZIP <br /> Stockton CA 95205 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEYY <br /> Mailing Address/fD/FFERENTtrom Fac/UtyAddress Attention:orCare Of(opt/onal) f�1 <br /> Mailing Address City STATE zip <br /> S E AN COMMENT: <br /> THIRD PARTY BILLING INFO: C piete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUS.NE".NAME Attention:orCare Of (Opt/Ona/) <br /> anced GeoEnvironmental Inc. <br /> dress PHONE <br /> 837 Shaw Road 800-511-9300 <br /> CITY STATE ZIP <br /> Stockton CA 95215 <br /> AqCoUArrAbQWW for fees and charges OWNER FACILITY/BUSINESS HIRD PARTY BILLIN <br /> BILLING AND COMPLIANCE ACKNOWLEDGME VT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERnnrFEES, <br /> PENALrms,ENFORCEMENT 0L4RGFs and/or HOuRLYCHARGEs associated with this operation will be billed to me at the address Identified above as the ACCOUNTADDRESS for this site.I also certify that all <br /> 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 <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,1 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 i avail le and at the same time it is <br /> provided to me or my representative. �2Z:� <br /> APPLICANT NAME(PLEASE PRINT) Ally Colavita SIGNATURE <br /> TITLE TAX ID# <br /> Project Scientist 68-0354606 <br /> Approved By Data AccountinilrOffice Processing Completed By Date y <br /> SITE MITIGATION I AMOUNTPAAI^ID DATE }�PA�YMENT PAYMENT PE RECEIPT 6 CHECK* RE ED _i <br /> ♦yORk PIAN P4Y� <br /> FEE:S p q�J// e V V 1 <br />