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San Joac County Environmental Health Del, ment <br /> DATE e/ , `-%�' =J MAS 1 CR FILE RECORD INFORMATION��I�FR � GREEN FORM <br /> v, /11 �(� v� SITE MITIGATIONf�1I &'LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER CASE ff UNIT '` <br /> V <br /> amrm RILE.COMPLETETHEFOLLOW/NG PROPERTY OWNER INFORMATION: CHECK/F OWNER CuaRENrtrONFILE wiTH EHO El <br /> PROPERTY OWNER NAME (908)276-4000 <br /> First MI Last PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> The Newark Group,Inc. ppp <br /> Owner Home Address O�v{+ 0 <br /> ZIP <br /> City �� STATE <br /> -� =OY,x> DEC 2 201 <br /> Owner Mailing Address 20 Jackson Drive <br /> I_TH <br /> tleil(ng Address City Cranford SNJ te Zi07016 PERMIT/SERVIC S <br /> CORPORATION® INOIVIOUAL❑ PARTNERSHIP-0 FED AGENCY❑ OTHER❑ <br /> Dim Pa maAT10N_ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP_WATER QUALITY_HW PIPEUNQ INVESTIGATION_LOP_ <br /> FACILITY ID# INvi! ACCOUNT ID PR t1L R01? <br /> w i M41 <br /> PA0111 V FIS COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE INFORqAT/ON: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No IN V \vJ <br /> IS this an EXISTINo Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO ® <br /> BumstmeWAOUTY/SITEN Former Dopaco C_ <br /> SITE ADDRESS / / SURE# BUSINESS PHONE C <br /> 800 W.Church Stree <br /> n <br /> CITY Stockton STATE ZIP <br /> CA 95206 <br /> CoAno OF St1PERVIsost DISTRICT LocATIoN CODE KEY1 t. M 2 <br /> t tiling Address ifD/FFERENT from Facility Address Attention:or Care Of(optional) <br /> 20 Jackson Drive <br /> Meling Address City STATE 5016 <br /> Stockton NJ � <br /> 816Cboe APN# COIi1CIENT: <br /> �J <br /> IPAwrY Elu ma INFO: Complete if Billing Party is different from Property Owner orFacillty O erator identified above. <br /> BUsiNEtis NAME Attention:orcare Of(optional) <br /> t"oNMag Address PHONE <br /> CRY STATE ZIP <br /> for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILUNG <br /> ffiJdlfG AND COMKIANCE ACKNOwLtDCMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERM?FEES, <br /> PENAL.Tms,EAToacEmE.vr CHARGFS and/or HouRLrCHARGEs associated with this operation trill be billed to me at the address identified above as the ACCOUNTADDRESS for this site. I 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 t Bove faciUq/site a ess,1 hereby autho the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM as soon ss/rt Is avails and a same time It is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) Peter Krasnoff,WEST,Inc. SIGNATURE <br /> TITLE President TAX ID# <br /> 68-044403 <br /> Approved By. Dnb -A000tntinp Oflios Procwing Cc PlatedEly Osb <br /> S"MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT RECEIPT.0 CHE K 0 RE <br /> fEE:;��_ / SIO BY <br />