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San Jo_ lin County Environmental Health G rtment <br /> DATE MASTER FILE RECORD INF RMATION "MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADED AREAS FOR EHD U4E ONLY OwNren ID# CAS # D�L 3 9.aZ-� U N fT IV <br /> OWNER FILE:COMPLETETHEFOLLOWNGPROPERTY OWN ERINFOR TION: CHECKIFOWNER CVRRENTLYONFILEwimEMD <br /> � <br /> PROPERTY OWNER NAME TERRY CDONALD (209)969-6686 <br /> First Mf La t PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> MCDONALD DEVELOPMENT COMPANY INC <br /> owner Home Address <br /> NA <br /> City STATE ZIP <br /> NA <br /> Owner Mailing Address <br /> 345 N YOSEMITE ST#13 STOCKTON CA 95203 <br /> Mailing Address City State Zip <br /> CORPORATION® INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MmaAmm_EpmRONmENTAL AssEssmENT_VOLUNTARY CLEANUP_Wl ATER QUALITY_HW PIPELIN WVESTIGATION I.OP X <br /> FACILITYID# INv# AccoutiTlD PR <br /> IFACILITYFILE ComPLETErtrEFOLLOwrNGBUSINESS IFACILITY ISIT ff INFORMATION: <br /> Is this a NEW Business Loc nom not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes ❑ No <br /> Is this an ExISTINO Business LOcAT10N but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESSIFACILITY/SITE NAME <br /> FIVE STAR MARINA EAST <br /> SITE ADDRESS - SUITEA BUSINESS PHONE <br /> 345 NORTH YOSEMITE STREET 209 969-6686 <br /> Cm STATE IJP <br /> STOCKTON CA 95203 <br /> BOARD OF SUPERVISOR K R DtmicT LOCATIOtf CODE KEY1 KEY2 <br /> Mailing Address/f01PFERENTfitvmFaalHyAddress Attention:orCare Of(opUmml) <br /> Mailing Address City STATE ZIP <br /> SiC CODE <br /> tAPN# COIHIIEIIT: <br /> THiNn PARw QILLING INF02 Complete if Billing Party Is different from Property Owner orFacllity Operator identified above. <br /> BUSINESS NAME Attgntinn:arCare of (optional) <br /> ADVANCED GEOENVIRONMENTAL INC. <br /> Mailing Address P"GI4 <br /> 837 SHAW ROAD 800 511-9300 <br /> CITY STATE ZIP <br /> STOCKTON CA 95215 <br /> for fees and charges OWNER FA iuTY/BUSINESS HIRO PARTY BILLIN <br /> SILLFNG AND COMPL[ANC6 ACKNOWLKDGMBNT: 1,the undersigned Applicant,certify that I am the Owner,O trater,or Authorized Agent of this Business,and I acknowledge that all PERART FEES, <br /> PeNALnFS,ENFORCF.,VENT CWARG-Is and/or MOURLYCHARGCS associated with this operation will be billed to me at he address identified above as the AcrouNTADORFSS for this site.i also certify that all <br /> Information provided on this application is true and correct,and that all re&dated activities will be performi I 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 property located at the above faciII /site a I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMEW AL HEALTH DEPARTMENT as An 1t is afallable and at the same lime It is <br /> provided to me or my representative. <br /> APPLICANTNAME(PLEASE PRINT) ROBERT E. MARTY SIGNATURE <br /> TITLE ., ., TAX ID# <br /> PRESIDENT 68-03 606 <br /> Approved BY Oate Accounting Office Processing plated By Date Z <br /> SITE MIT ATION AMOUNT PAID DATE Ot%PAYMENT PAYMENT TYPE RECEIPTS GHECK# RECE1VE08Y wOnr�P, <br /> FEE�}- <br />