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0 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE11 MASTER FILE RECORD INFORMATION"MFR» GREEN FORM <br /> SITE MITIGATION& LOP <br /> SHADED AREAE FOR ENO)VAR ONLY OWNER IDM CASEIN UNIT IV <br /> OWNER FI LE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: Cmwx Be OWNER Is CuRRfwLrowPa.E wire,END <br /> PNOPERTYOWNERNAME Ron Browne 800' Sol-SSR9 <br /> Fmr MI LAST PHONE NUMBER <br /> BUSINESS NAME WAA.Z.Stockton,LLC E 11.ADDRESS <br /> OWNER HOME ADDRESS <br /> Cm STATE LE <br /> OWNER MAILING ADDRESS 2402 S.California Street <br /> MAILINGAoDRESSCm Stockton STATE CA LP 95206 <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION .. _ ENVIRONMENTAL ASSESSMENT X_VOLUNTARY CLEANUP WATER QUALITY _. HW PIPELINE INVESTIGATION LOP <br /> FACIUTYIDM INV# ADDoUNTID PR#IRO0 ASSIGNED EMPLOYEE t <br /> LEAD AGENCY:EHD RWOCB DTSC EPA <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS ANEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ® No ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,RUTA NEW SCOPE OFWORK? YES ❑ No ❑ <br /> BUSINESSIFACILm/SITFJPROJECT NAME White Arrow <br /> SITE ADDRESS I PROJECT LOCATION 2402 S.California Street SUITES BUSINESS PHONE <br /> (800)5015589 <br /> CITY Stockton STATE CA Zip 95206 <br /> BOARDOF SUPERVISOR DISTRICT LOCATION CODE KETI KEN2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILm ADDRESS ATTENTION:OR CARE OF(OPTIOAML) <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME Panner Engineering and Scienfc.Inc. Arnit"oN:ORCARE OF(DRWONay Samantha Harris <br /> MAILIMRADomm ce PHONE <br /> 2154 TemmBoulevard.SUIIC 200 310-6I5-0500 <br /> Cm <br /> Torrance STATE ° <br /> 9Uiul <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNERO FACILITYIBUSINESSO THIRn PARTY BILLING <br /> Rtl v'\sn CII\IP-IANCE ArI:wseTrncafs: LlM1r undersi�nrd.\pplicRnl,cenifv rlmll aro the Nwner.Opaarm',:Urt/arria•J,Iprnr.nr RespnnsiMr Pony and/acknuxledee/hal all/•ER111r FELr, <br /> PEA Im".EYmat F-VENI CILIRGLT nndor Hof MO LT[Imucs,Rssueiated nigh this projeel hill be Dilhd to me W the address idemined abmr as dA.l['rm\r.ADnResi fw This s0e. 1 ar o rerlih IhM all <br /> information IOLRidod on this 411110radnn is Irae and cm"I:and that all n'eulRled Ind,iths will be rfin Bad in aemrdarre ailh all 4MAIC111,1e SAN JO.\Gr11 COISIY OIIIONANO:COOCN And/or <br /> St mAnDs and STATE Rather fEDLR\I.I.aas and RECVIAT1ON9. As the undemiLNled Ona,,.Oprnrtor..IIRINai3Y1.4,Ien4 nr Relpa oihle PosDe for the prejwl I"Aled alane ander haililyishe nddress,I <br /> hereby aulhadn rhe release of eny and ad resWD,mparts,And Other mirRllmenud n'sv,Amvnl intinawlion la SANJOADUIN COURr) EN\INOS)IENI AL IIfAL'rlt OCP\N1s1F.hl A'Slrov x'i16 tlrWlahlc <br /> and m the same lime 11 u prvsideJ la me or my npresevlatke. <br /> APPUCANT NAM(PLEASE PRINT) Samantha Harris SIONATIRM <br /> TITLE Senior Project Manager TARI�O-R'-6;379 <br /> APPROVEn BY DATE ALWIIMING OFfILE PROCEBBING COMPLETED RY DATE <br /> SITE MITIGATION AMOUNT PAIU GATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED 131 WORK PIAN PE <br /> FEES <br />