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Unchanged since submitted ; November 2012 <br /> San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADEDAREASFOREHDUSE ONLY OWNER ID# FCASE* UNIT IV <br /> OWNER FILE:ComPLE1FmEFmLOWINGPROPERTY OWNER/NFootzxiimw.- CHECK,FOWN EROLMRENIXyOw nLEig"n,EHD� <br /> PaoPERTYOWNER NAME (209)629-5070(Ask for Sam Franco! <br /> FIrsl M/ Last PHONE NUMBER <br /> BU31wm NAME E-MAIL ADDRESS <br /> The Newark Group <br /> Owner Him Address <br /> city STATE ZIP <br /> Owner MallkVAddraas 2575 Grand Canal Blvd <br /> MaNklg Andreas <br /> 'tty <br /> Stockton to CA Zip 95207 <br /> CORPORATION!© INDIVIDUAL❑ PARTNERSHIP❑ FEo AGENCY❑ OTHER❑ <br /> Srm MITIGATION_ENVIRONMENTAL Assessmiew \VOLUNTARY CLPANUP_WATER QUALITY_H1111 Pt#!LINE INVIRSTICATION LOP <br /> FACILITY IDX INv# ACCOUNT ID Pit*JRO* AssIGNEDEMPLOYEE I LEAo AGENCY:EHD_RWQCB DTSC_EPA <br /> FACILITY FILE COINPLE7E TNEfOLLOW NG BUSINESS/FACILITY/SITE INFORAH noN.- <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES 0 No El <br /> Is this an ExisTlNo Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No D <br /> BUSINESSIFACILITYIStTE NAME <br /> SITE ADDRESS 800 West Church St ("Dopaco Area"only--see attachment) SUITE# BUSINESS PHONE <br /> CITY STATE ZIP <br /> Stockton CA9520 <br /> BOARD Of SUPERVISOR DISTRICT LOCATION CODE KEY1 K"2 <br /> Mallli Address AIORIffERENrf m Ficl V AttVa v" Adention:orCam Of(apduna/) <br /> Halling Address City STATE ZIP <br /> SIC COOE APN* 2 COMMENT: <br /> fN <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BtIstNEss NAME C AUentlon:orCare Of(OPO-Mal) <br /> A s c ARCS Q1� 2 / 7 <br /> MWIkVAddresa PHONE OI f Jac 5 /02 <br /> --TT--t�� 40 g M A�.IE`-1(I c_TC)R.I.N t'.�i.._U C� <br /> CITY K N CG �/ �' P-1,LLS STATE c�" -'0 A 160 <br /> ACICOUAlr tL:affiEeQ for fees and Charges OWNER FACIUTY/BUSINESS THIRD PARTY BILLING <br /> Bit 1.1%il%%D fuNpl t�K f. 1CAw++t.t.u<,+tt.N 1: L the andtnigned ApplitanL certify that l aus the lbsner.Oprrnn�r.or•l ulknri;ixl At:en1"f,the u t(-I.and l for <br /> IJKe te. !..ko cirrsn Pt Fs. <br /> pf v4i ryus.F+fURt'Est'%,I 01.tN<,t1 snd.'or fdnl'lu YC//1Rt.Et'assodatnl w 5th this operation will he hilted to me at the address identified al,o%r a+the l/t In+/-I/l/IAC:cK for Ihls situ. 1 .o certif that <br /> Jill information prodded on thi<appbcafion is lnte and correct:ant!that all regulated ai:16ities will be performs!in accordance with all applicahle S%N J0.tQ1'I�COr1T1 Ur�d, ce l'nde.and'or <br /> Standards and til A t f.and/or Ff UIR U.1.1%e and Regulation.. As the undersi¢ned oxner.operator,or agent of the propern Ioea[ed al the allose foci ttyhite addrn.•.I hereyY;ituthoiue the release of <br /> anmenvironmentalaaee <br /> y and alt mutts and asmm <br /> ent information to IA SAN.IO.�QUIV COL ENVIRONNIF N1 Al,HF,of Ll 11 DE.PAR1 HIEJN . soon as is It as�ilntile and at the tame rime it is <br /> prodded to nu or my repre entath e. <br /> �/� T- NEA <br /> APPLICANT NAME(PLEASE PRINT) EC) hf 1 1 A 1 v SIGNATURE <br /> TITLE \ P E N R6 N M E Q T T # �o`C A;PL\CACKLE �CAt>ACsinn4 C1J <br /> Approved By <br /> Data Aecountln Office Proeessl Completed B Date <br /> MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT* r- <br /> SITE <br /> K# RECEIVED BY WORK PLAN PE <br /> FEE.A' <br />