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San Joaquin County Environmental Health Department DATE 1/25/2011 MASTER FILE RECORD INFORMATION"MFR" GREENFORM SITE MITIGATION& LOP SHAoEDARE•S FOR EHD usE ONLY OWNER ID# CASE# S� OO UNIT IV �bb2. OWNER FILE:COMPLETE THEFOLLOW/NG PROPERTY OWNER INFORMATION. CHECKIF OWNER CURRENTLYONF/LEW/TH EHD PROPERTY OWNER NAME The Newark Group (209)629-5070 (Ask for sam Franco) First MI Last PHONE NUMBER BuawmNAME The Newark Group E-MAILAODREss Owner Home Address city STATE ZIP Owner Meiling Address 2575 Grand Canal Blvd Mailing Address City Stockton State CA LP 95207 CORPORATION® INDIVIDUAL❑ PARTNERSHIP❑ FEOAGENCY❑ OTHER❑ SITO MITIGATION—QNVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP_WATER QUALITY—HVI PIPELINE INVESTIGATION—LOP FACILITY ID# INV# ACCOUNT ID PRN/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB—DTSC_EPA I 0i _ 11INC3 3 12 FACILITY FILE COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE/NFORMAT/ON.' Is this a NEW Business LOCAnoN not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ® gz=r Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ® '=ZZZ' BUSWEss/FAauTYISITE NAME SITE ADDRESS 800 West Church St SUITE# BUSINESS PHONE CITY Stockton STATEZPCA 95203 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 Mailing Address HDIFFERENT/romFaopllyAddress Attention:orCarsOf(optiona) Mailing Address City STATE ZIP SIC CODE APN# COMMENT: i THIRD PARTY LING INFO. Complete if Billi'hg Party is different from Property Owner orFacility Operator identified above. BUSINESS NAME Geosyntec Consultants Attention:orCare Of(optional) Mailing Addr 475 14th Street,Suite 400 PHONE 510-836-3034 CITY Oak nd STATE CA ZIP 94612 AccomyrAWAE;�* fees and es OWNER FACILITY/BUSINESS THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Aulhorized Agent of this Business,and I acknowledge that all PERMITFEFS, PENALTIES,L'NFORCEAIENTCHARGES and/or HOURLY CILIRGES associated with this operation will be billed to me at the address identified above as the AC1000NTADDRESS 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 HEALTH 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 SIGNATURE 1 TITLE Engineer,Geosyntec Consultants TAX ID# 59 355134 UVI j�I ;VI 1I11L- rove l By Date Accounting OMoo Proceaehlp Completed B �s� Date SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECKS RECEIVED BY WORK PLAN PE FEE: