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San A uln County Environmental Health Oartment <br /> DATE 10/10/2014 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> $HA PED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETE THE FOLLOW/NG PROPERTY OWNER/NFORMAT/oN. CHECK tF OWNER CURRENTLYONFILE WITH EHD <br /> PROPERTY OWNER NAME <br /> First M1 Last `PHONE NUMBER 209-482-3190 <br /> BUSINESS NAME Mr. Jim Weber and Mrs. Karen Weber E-MAIL ADDRESS <br /> Owner Home Address 2229 Manzanita Court <br /> city Lodi, California, 95242 STATE ZIP <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> CORPORATION❑ INDIVIDUAL ID PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP XX WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INV# AccouNT ID PR#/RO# �' 1' <br /> t;_ � <br /> }- <br /> FACILITY FILE COMPLETE THEFOLLowINGBUSINESSIFACILITY/SITE/NFORMA77om, <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an ExISTING Business LocATION but a NEW TYPE of regulated Business? YES No ❑ <br /> BUSINESS/FACIUTY/SrTENAME APN 043-023-01 <br /> SITE ADDRESS 230 North Church Street, Lodi, California SUITE# BUSINESS PHONE <br /> CITY STATE Zip 95240 <br /> BOARD OF SUPERVISOR DISTRICTLOCATION CODE KEY'I KEY2 <br /> Mailing Address WD/FFERENT from FacilityAddness Attention:orCere Of(optional) <br /> Mailing Address City STATE zip <br /> [S�--E APN ') —02 2 Q COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Advanced GeoEnvironmental, Inc. Attention:orcare Of (optional)wi l l i a m little <br /> Mailing Address 837 Shaw Road PHONE <br /> CITY Stockton STATE CA ZIP 95215 <br /> A4SS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Appllcant,certify that I am the Owner,Operator,or Authorized Agent Of this Business,and I acknowledge that all PERMIT FEES, <br /> PENAL77Es,ENFORCEMENT CHARGES and/or HOURLY CMARGES associated with this operation will be billed tome at the address identified above as the ACCOIINTADDRESS for this site. 1 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,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 /> APPLICANT NAME(PLEASE PRINT) {nIy ,� (�. SIGNATURE <br /> TITLE TAX ID# C <br /> Approved By I Date F Accounting Office Processing Completed By Date <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLANPE°' <br /> FEE:$ <br />