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4 7 <br /> San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> 5e0067075-7 <br /> D C SITE MITIGATION&LOP <br /> M SQo0 <br /> SHADED EASFOR EHO USE ONLY OWNER ID# CASE# G7o57 UNIT IV <br /> OWNER FILE:COAfPLETETHEFOLLOWING PROPERTY OWNER INFORMATION: CHEcxir OWNER cuRRennroWrxeFwrH EHD� <br /> PROPERTY OWNER NAME (209)629-1070(Ask [or Sam Franco) <br /> Ftr<f MJ Last PHONENUMBER <br /> BUSINESS NAME C-�1AIL AQDRESS <br /> 'ne Newirk Group <br /> Owner Homs Address <br /> city STATE ZIP <br /> Owner Mailing Address 7575 Grand Canal Blvd <br /> Mailing Address City Stockton state CA ZIP 9?207 <br /> CORPORATION© INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION_ ENVIRONMENTAL ASSESSMENT Y VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP_ <br /> FACILITY ID# INV# ACCOUNTIO P it ROS AssiGHEDEMPLOYEE LEAOAGENCY:EHD_RWQCB-X—DTSC_EPA_ <br /> oHA)Vy <br /> FACILITY FILE COMPL THt:FOLLOWING BUSINESS/FACILITY/SITE INFORMATIOIN' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO Q <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No ❑� <br /> BUSINESStFACILITTISITE NAME <br /> SITEADDRESS 900 +,West Church SI ("Dopaco Area"only--see attaclmient) SUITE# BUSINESSPHONE <br /> CITY STATE ZIP <br /> Stockton CA <br /> BOARD OF SUPERVISOR DISTR{CY I LOCATION CODE r KEv1 KEY2 <br /> Mailing Address No/FFERENTfSomfacft/fyAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# ^ �S� �e)� f+OMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME ^ S {� G •�- c� I Q Attention:orCere Of(optibnal) <br /> /--\ t.-] J -.t_.S V PHONE 1 <br /> _____ ._11ta111ag.Addtsss___ �-�--0)LO `� •�� --- . <br /> ._ r. .. <br /> CITY <br /> KI N G C`/ 9F- At—S STATE t�Qe ae Cz'P 3 O A'.60 <br /> ACC6uATAa0aess for fees and charges OWNER FAciLiTY/BusINESS "� THIRD PARTY BILLING <br /> Ito t.Icr,t�D KNo tt Lt Dc.Nl!Lr: I,the anelcrcig—1 applicant,—fir,that 1;....Ibe Onn,r.01n•rat,,r.or.Italwi-icrd.fgcnf of Ihia It—iness,and I at-1,.nn Icdge dtaI all PFR 1111'f f 5. <br /> PEti�l.rtfv,F%foxt.tJ7Ls7 Cn-txt,G•-SandJt•r 1fu17<7 i'C//1xoESaswiiatatil with 11ris op".1itm nal he billed to me at the addrcac identified ab—o.,,th-11 t runt:I7VtRtCKy for Ihi>cite. 1 5a -elIlial <br /> all inrormalinn pro.idnl nn IhN application is(,,to and correct:and that all ropl:lled aclicitics trill be performed in accordance wish all applicable S%V JOAQI TN COt NI'i Onf ce('odes andlor <br /> Standards and$T.tlE.tndlnr FEI5IPR 1L La+cs And Rt�utalinns. As lite undersigned on nor,operator,nr agent or the proper I)Inca toil n1 the all-e Sari lit 1>ite add Ices,I lit,rebv:itihnrile the relraae of <br /> any and all rewlty and environmental asaec•tucntin(trmalion fit SAN JOAQUIN COUNTY ENVIRONNIEv'I'AI,IIF.a1,I 11 DFP.\K'1}tE\Tenon ac if is ace Jabk a tl et the same tine it i <br /> prof idt.l to the or my representative. '151 <br /> ..:�.� — <br /> APPLICANT NAME(PLEASE PRINT) E c-) �,J IZ1 N E=:-A U SIGNATURE �� "% <br /> TITLE n E v 2 C3 N �-1 N-►- Tnx.l <br /> ApprovedBy Dats Aecoun6ngtmee Processing Completed By Dale cJ <br /> RECEIVED <br /> SITE MITIGATI Au---PAIp n•Tc nr oevMFNT PAYMENT TYPE RECEIPTS CHECK* BY WORK PLAN PE <br /> FEE:s" <br /> ;`?4 0 <br />