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Unchanged since submitted lovember 2012 <br /> San Joaquin County Environmental Health Department <br /> DATE ,22.(2, MASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> $ITE MITIGATION&LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER IDN CASE SRL04782.si�r UNIT IV <br /> OWNER FILE:CaVPLETETHEFOtLOWlNGPROPERTY OWNER INFORMATION: CiwmArOWNER CUaRENnro Flt--wrmEHD <br /> PROPERTYOWNER NAME (209)629-5070(Ask for Sam Franco) <br /> Flist M/ Last PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> The Newark Group <br /> Owner Hann Address <br /> City STATE ZIP <br /> Owner Mailing Address 2575 Grand Canal Blvd <br /> Mai"Address City Stockton State Ctrl "P 95207 <br /> CORPORATION Q INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SrrE MMIZAT1ON_ENVIRONmaNTAL Aliso ENT X VOLUNTAIIY CLFANUP_WATM QUALITY—HW PIPELINE INVEMOATION_LOP <br /> FACILITYIO# INV# AcCOUNTID PR#IRON FAStt LOYEE LEAD AGENCY:EHD_RWQCB_DTSC_EPA_ <br /> FACILITYFILE COMPLETETHEFOLCOWNGBUSINESS/FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION riot 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 Q <br /> BusINess/FACILITY/SITE NAME <br /> SITE ADDRESS 800 West Cliurch St ("Dopaco Area"only--see attachment) SUITE# BUSINESSPHONE <br /> Cm Stockton STATE CA IJP 9520; <br /> BOARD OF SUPERVISOR DISTRICT /y I LOCATION CODE 0 I KEYS KEY2 <br /> Mailing Address/fDM'FERENTf m FeeflAyAddrtess CJ Attention:orCaro Of(aphbrtalJ <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN N 11415- 23<-) y COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is-7differentfrom Property Owner orFacility Operator identified above. <br /> BUSINESS NAME G A S G. F"'i � C S T—� C Attention:or'Care Of(opOloniso <br /> Mailing Address /� PHONE 81 C) - 3 3 5 702 <br /> T►,t 40�r--r���z(>;.`-`v1c.To�ZN t�u � �t <br /> CRY KIN N G�G= � � fV L-1-..� STATE t OG OvE e" -70 A 160 <br /> Acct\mTAoaem for fees and charges OWNER FACILITYIBUSINESS {� THIRD PARTY BILLING <br /> Rn I.Isr;s%D COMPIJA\CF,.%C1,she undersigned Applicant,crrtifv that I am the rhwm Operator,or,balntriced Ag-1 of thin Ilusiness.and 1 sit los"leslgr that all PERM/,FFf.1. <br /> PF%;tLm..%.F\F0RL"F..4lh\'1 1LII4R1,kS and1or Hot'RL V C11m.E5 mssociated with this operation#sill be billed tonic at the address identified above as the-1rt d wAl•l1R1. for this site. I o crrtif�11111 <br /> all information prosided on this application is free alai correct:and that all regulated activities trill be pe•formcd in accordance with all applicable xv-1o.apt IN CotNiv Orth! Code,amllor <br /> Standards and Srs tE end/or FF DPR st.crus and Regulations As the undersigned on ever,operator,or went of the properp located at the ahnse farthhfsite addtcss.I hers bb� U ttor've the relrlse of <br /> any and 211 results and entironmental assessment information to SAN JOAQ1.IN COLI\`T1'ENVIRONMENTAL HEAL 111 OkPAR]VIEN %�oon as it i�eadabte:nd at the came rime it is <br /> pros idol to me or nay representafisr. r� <br /> APPLICANT NAME(PLEASEPRINT) l�J M A i:L NEA U SIGNATURE fir/ <br /> TITLE V P E N V r R c5 N M (.)T Tl x l # o-r L c a QLE �GF4iJAni n tJ CCs) <br /> A roved By Oate <br /> FFA eeounitn Office Processing Completed By Onto <br /> SITFMITIGAT19N AMOUNTPAID DATE OF PAYMENT PAYMENTTYPE RECEIPT CHECK# RECEIVED BY WORK PLAN PE <br /> FEE:S 2W <br />