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Unchanged since submitted inoember 2012 • <br /> San Joaquin County Environmental Health Department <br /> DATEMASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> 9 lsENDumONLY OWNER 100 CASED UNIT IV <br /> OWNER FILE:COMPLEMTHIFFottoN7NOPROPERTY OWNER fillmmar/Ofw C„ KAI,OWNER OAwErsrol.DENIrNENO E] <br /> PWPPATT OWWER NAME (209)629-;070(Ask fnr Sam Franco) <br /> Fnal MI Leal PNDNl NUMeEA <br /> ENAAILADDRESS <br /> BUSIHfSSNAME <br /> The Newark Group <br /> O,san r Hanes Address <br /> CRy STATE LP <br /> Owner Mailing Address 2575 Grand Canal Blvd <br /> Mailing Address City Stockton se to CA 71P 95207 <br /> CORPOM"ONw INDARDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTNER❑ <br /> Srn!MmGATION_ENVIRONMENTAL ARRERfMENT X VOLUNTARY CLEANUP_WATER QUALITY_HW PIPKJNS IHVEsmGATIDN LOP_ <br /> FAciuTTlOt Ixvd AccOUNT ID PRINROI ASSIGNED EMPLOYEE LFAD AGENCY:EHD_RWQCEI_DTSC_EPA_ <br /> ; p� A -Do2Il9 ' <br /> FACILITYFILR CoMptEmrHEFoaowNGBUSINESS IFACILITY/SITE IlvFORMA710M. <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ ND <br /> Is this an EXISTING Business LOCATION beta NEN TYPE of regulated Business? YES-❑ No 0 <br /> UUSINESSIFAC ILIVYISOE NAME <br /> SHITE# SUSINESSPHONE <br /> SGEAOORE99 800 WestChurch St ("Dopaco Area"only--see attachment) <br /> STATE LP <br /> CITY Stockton CA 95203 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEPI KEY2 <br /> Malllrlg Address I/DIFFEREAfrthNnFaOWAddmm Attention:wCam Of(apillarI <br /> Mailing Addm"City STATE LP <br /> SICCODE APN0 COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> SUSINEss NAME <-- A •!S G A f�a S Z n <br /> NI C AtteUox:orCiere Of(op&vwq <br /> Mss Address r"T PHONE 81 C1 . 3C� 3 - IS 702 <br /> 404 MANE- ViC-To IN t3-V L'� <br /> CM KSN C STATEQQr-leCzn` Z'OA 160 <br /> AccauYTADaRF$Q for fees and chargee OWNER FACILITYIBUSINESS 1Y�V THIRD PARTY BILLING <br /> nll.l l\C\\D C04PLIA\CE <br /> 1,CWN0 I.MW.N16Nr: I h J. ignnl APpl ne,CerliH lhul l um lhr rhlYfrrt t)IINn/for.ur:InrGnrinrlaganf of lhia gU5in65. nJ I P1'Iuluv lrtlge lhal oil PFplf/T Ff.FP. <br /> PETU.nEr:CA FI/Re sm11 c ,,N,LVanJlur II I, NNh diiS operation n ill he IIiIIN in tor at the addrexa idvn lifed 1JIYYO as Nlrih...,w.J h/wm fOr I hi,e: 0ee,hfr Thal <br /> sill infenlladnn Drm ided nn IN,appli4lian iY Irue and vinrHn and that IIII relin riNd Rel vilim all ImpIDYPobnerl IO Yit.rJnnec With All.,plieDille NANjo.AQl IN Co NIY'Ordv tr C91.iaJ/nr <br /> $lanitafda andSfAD:andhle FFutlp lL laW sanU ltegulalinna ds Ale nnJelsigned Oxner,0perolnr.Urgent Pf tha pmperry lRLYIHI al the sham fan inFfleadJros.l herc4//y1°ithirize the relearn ul' <br /> any and all results and em4onmenad+ons sno l infor.own,ul SAN JOAQUIN COUNTY EBYIROSIl1EN'I'AL IF.It L rH OEPAR'I'IF mnn ss it ix alvjlA�lsand al the fame Lime it is <br /> preciJtd to me nrnly rcprcneNadce 1 /f oT ��'��'��/��/ <br /> APPLICANT NAME(PLEASE PRINT) LEo l,f I / t,r-.,L_ NI_t,U SIDNAruREi'� 'if <br /> TITLET�0 <br /> X11' E N V 12<5 N N1 E Q T vo� A?DL.tGta131.E �C�,HSataianl ct,) <br /> A Proved eY Dab AetewlNepPrmwi ComPlaladSo Dela <br /> SITEMITIGATION AMOUNT PATO DATE OF IAYYENi PAYMENT TYPE RECEIPTS CHECK SREOEIVEDBY WORK PIAN PE <br /> FEE:: <br />