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0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADED AREAS FOR END USE ONLY OWNERID# CA6Eis UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK or0"ERIS CURRENrcr ON FRE WITH E H D <br /> PROPERTYOWNERNAAIE Ron Browne 800) 501-5589 <br /> FIR6T MI LAST PHOKENIIMSER <br /> BUSWfSS NAME W.A.R.2.Stockton,LLC EtilAiI ADDRESS <br /> OWNERHOMEADDRESS <br /> CI STATE ZIP <br /> OWNER MAILIND ADDRESS 24025.California Street <br /> MAium ADDRESSCrtY Stockton STATE CA LP 9520b <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ®RESPONSIBLE PARTY ❑OOIER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP_WATER QUALITY— HW PIPELINE INVESTIGATION LOP <br /> FACIIJTY ID INV# ACCOUWID PR#IRO# ASBNSNEO EMPLOYEE LEAD AGENCY:EHD_RWQCB_DTSC EPA_ <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY TH E ENVIRONMENTAL HEALTH DEPARTMENT? VES ® NO ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES ❑ NO ❑ <br /> BUSINESSIFACIUTY/SRE/PRO%ECT NAME White Arrow <br /> SITE ADDRESS I PROJECT LOCATION 24025.California Street SUrtE# BUSINESS PHONE <br /> (800)501-5589 <br /> CITY Stockton STATE CA LP 95206 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE NEYT KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> MAIUNG 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 Partner Engineering and Science,Inc. ATTENTION:CRCARE OF(CPn )Samantha Harris <br /> MAILINGADDRESS <br /> 2154 Torrance Boulevard,Suite 200 PHONE 310-6154500 <br /> Cmc STAR LP 90501 <br /> Torrance CA <br /> ACCOUNT ADORESE TO SEND ME$AND CHARGES: OWNERD FACILRYIBUSINESSI] THIRD PARTY BILLING® <br /> $LI NC AND COTIP ANCE ACKNOWLEDGMENT: [,the undersigned Applicant,certify that I ail the OuTter,OPOMOr,Aurharivd Agtnf.or Re pneoible Parti and I aeknoNtedfe that 811 PERMIT FEES, <br /> PE.\aT,E,EVFORCEVEYTCl/IRGES and/or floi FLr CHJRGES cessee aled n'Ith(his project nfil he ladled tow at the addecu IdeatlRed eha\e its IlH ACCOI ITADDRFSS for this site. 1 ato cerdfy th81 idl <br /> information provided an thb applicatimn is true and correct;and that all regulated acHrltle5 gill be performed ID accordance xflh all applicable SAN JOAQUIN COUNTY ORDINANCE:COIDEN and/or <br /> STA>DARDS a ad STATE and/or FEDERAI.Laps and REGI:LATIOSS. As the undersigned Owner.0,naor,Aulhodwd Agent or Responsible Parry for the project luraled above under facilihlsite address,I <br /> hereby authorize the release of any and all results reporn,aad other environmental a.....cut infornetion to SAN JOAQUIN COL\TY ENVIRONMENTAL HEALTH DEPARTnIEN'r M soon as it is evailahie <br /> .ad at the same time it is provided to.or an,representathe. <br /> APPLICANT NAME(PLEASE PRIM) Samantha Harris SIGfUTUR! <br /> TITLE Senior Project Manager TAXID# 20-8264379 <br /> APPROVED$Y OAR ACCOUMING OFFICE PROCESSING COMPLETED BY DAR <br /> $ITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PIANPE <br /> FEE:; <br />