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• San juin County Environmental Health )artment • DATE 1/zs/zoll OR M/7►STER FILE RECORD INFM ` GREEN FORM --L TE MITIGATION & LOP SHADED AREAS FOR EHD U9EONLY OWNER ID# ��<g6bj 00 UNIT IV FOWNER ILE:CoAfPLETETHEFOL L OW/NG PROPERTY OWNER/ OR TION. CHICH/F OWNER Cum TLYONF/LEwiTH EHD El PROPERTY OWNER NAME The Newark Group /oo( Z (209) -5070 (Ask for Sam Franco) First Ml Lo P UMBER BUSINES3NAME The Newark Group E-MAIL ADDRESS Owner Home Address City STATE ZIP Owner Mailing Address 2575 Grand Canal Blvd Mailing Address City Stockton ---FState CA zip 95207 CORPORATION© INDIVIDUAL❑ PARTNERSHIP❑ PED AGENCY❑ OTHER❑ SITE MITIGATION—ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP FACILITY ID# INV# ACCOUNT ID PR#/RO# A89IGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB_DTSC_EPA FACILITY FILE COMPLETE'THEFOLL014— '-QU-8l NESS I FACILITY/SITE INFORMATION: Is this a NEW Business LOCATION not prevlou, _ NTgL HEALTH DEPARTMENT? YES ❑ No eg Is this an EXISTING Buslness LOCATION but a YES ❑ No BUSINESs/FACILITY/SITE NAME SITEADDRES9 800 West Church St I SUITE# 13V91NE89 PHONE CITY Stockton L STATE ZIP CA 95203 BOARD OF$VPERVISOR DISTRICT � LOCA.—_ EEY2= Mailing Address NO/FFERENTfrom Facll/tyAddress Attention:orCara Of(optional) Mailing Address City STATE ZIP SIC CODE �APN# COMMENT: THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. BUSINESS NAME Geosyntec Consultants Attention:orCare Of(optional) Mailing Address 475 14th Street, Suite 400 PHONE 510-836-3034 CITY Oakland STATE CA ZIP 94612 AccouNrAOyBFss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING BILLINC.AND'COMPLIANGE ACKNOWLEDG!LENT: 1,the undersigned Applicant,certify that I'am the Owner,Operwor,or Aufhorized Agent of this Business,and I acknowledge that all PERAtiT FEEY, - PENALnES,FNFORCEmovT CHARGES and/or 110URLYC1L4RGFS associated with this operation will tie billed to me at the address identified above as the ACCOUNTADDRF_CS for this site. I also certify that all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL f1EALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. APPLICANT NAME PLEASE PRINT Jackie Lanzon , �A- t I SIGNATURE TITLE Engineer, Geosyntec Consultants TAX ID# 59 355134 ffFEE:$ Data Accounting Offica Processing Completed By Date ION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE V I _. > IHIL