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San Joon County Environmental Health Dt Ament <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> OWNER ID/ DARE/ UNIT IV <br /> OVMER FILE"Cm [ww w PROPERTY OWNER 1AFFoRm77oN., 0mmlF OWNER Cvmu 7LroAFRLEw7w EHD <br /> PROPEIM OWNER NAM CPC Inc. Intl In redion (204 547-8233 <br /> First MI Last PHONE NuansER <br /> BuammsNmm Com Products US E-"LAoDw= <br /> Roger.Hoffdahl@comproducts.com <br /> Owner Home Address <br /> c/o Com Products, U.S., 1021 Industrial Drive <br /> cft Stockton STATE CA 95206 <br /> owner"IngAddress P. O. Box 6129 <br /> Mailing Address Ofty Stockton State CA TIP 95206 <br /> CORPORATION[25 INDMDUAL❑ PANTN R1"P❑ Fm Awom❑ OTHER❑ <br /> arra MITItI rm_[Nv11EowrrAL Assmiaiiiitiff_VouwAw CummuF_WATtot QuALrrY_H!r PltEkrn INvmi aATloN—LOP_ <br /> FAciurr 10/ INV/ AOoouNT ID PR Sf RO/ A Icp o EmpLOYEE LEAD Aasicar:EHD_RWQCB_OTBC_EPA_ <br /> FACILITY FILE 0nArPLETE7HEFouowlAoG BUSINESS/FACILITY/SITE/A/FoRm4T7ow <br /> Is this a NEw Business LOCATION not previm aly regulated by the ENVIRONmEHTAL HEALTH DtPARTMENT7 YES ❑ No [� <br /> Is this an Exisrwo Business LOCATION but a NEwTIPE of repUrbed BusirTess? YES ❑ No <br /> BUSNE381FACUTY/11"N"E Air Products&Chemicals, Inc. (Stockton Cogen Facility) <br /> SrrEADoRm 1010 Zephyr Street Surn/ BUSINEBa PHONE 707-748-7595 <br /> crTY Stockton STATE CA ZJP 95206 <br /> BOMMOFSUPERMSORD111TRI7T U)"TIONcow KE" KEY2 <br /> MaIHng Ad&vm/fD/FFB?BtfrftmAvaftAdinhw Atbnticn:wCare Of(apdarseg <br /> Mulling Address City STATE LP <br /> SIC COOS APN it COrrtsrt: <br /> THIRD PARTY BILLING INFO: Complete ff Billing Party/s different from Property Owner orFaclitty Operator identified above. <br /> SUMNEW SAME AS FACILITY OPERATOR ABOVE(Air Products& Chemicals, Inc.)A t L%(*' � <br /> Mailing Address SAME AS FACILITY OPERATOR ABOVE P"ONESAME AS ABOVE <br /> CITY STATE ZIP <br /> AaaWAMAppREw for fees and charges OWNER FAC LiTYBusINEss THIRD PARTY BiLL1NG <br /> DrLL1NG AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authortied Agent of this BotiueL%and 1 acknowledge that all PmWT FEESS <br /> ftx4LTas,EN oxczwFxTCH,utaes and/or HOVRLrCHARGas associated with this operation will be billed to me at the address Identified above as the Alc7LayfAyDRESS for this site I also certify fiat <br /> all 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 Coda 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,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 available and at the same time It Is <br /> provided to me or my representative <br /> APPLICANTNAME(PLEAMPRINT) Scot Govert Simuruim <br /> TITLE TAX I <br /> Principal Environmental Engineer FIDN 23-1274455 <br /> Dake ofte CornploWd Sy Data <br /> SrTTE MITIGATION AuoumT PAID DATE OF PAymEwr PAYuETIT TYPE ftcvPT/ CHECKS REDEwED BY wom PLAN PE <br /> FEE:I) <br />