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r <br /> San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADED AIR EAS FOR EHD USE ONLY OWNER IDS CASE tr ItI6, UNIT IV <br /> OWNER FILE:CommErE rHEfottow1NG PROPERTY OWNER INFoRmwyox.• CHECK/F OWNER CURREArnromFxEWRN EHO❑ <br /> PROPERTY OWNER NAME (209)629-5070(Ask for Sam Franco) <br /> Ftaf Mf Last PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> The Newark Group <br /> Owner Horne Address <br /> CRY STATE ZIP <br /> Owner Mailing Address 2575 Grand Canal Bled <br /> Mail"Address City Stockton state CA Zip 95207 <br /> CORPORATION© INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SfrE Mm"T1ON_ENVIRONMENTAL AtsP_WM[NT�VOLUNTARY CL[ANUP_WATm QUALITY_Hw PipwmE INVlfn",nON,LOP_ <br /> FACILITY 10 INVIf ACCOUNTID P RoS AssIGNEDEMPLOYEE LEAD AGENcY:EHD_RWQCB_DTSC_EPA_ <br /> FACILITY FILECollin=rwFottow(NG BUSINESS/FACILITY/SITE INFORmArioN: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENV YES ❑ No <br /> Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESSIFACILITY/SITE NAME <br /> SITE ADDRESS 1r 1r SUITED BUSINESSPHONE <br /> 300 West Church St ( Dopaco Area only--see attachment) <br /> CITY <br /> STATE ZIP <br /> CA 957 <br /> Stockton 0.11 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE ' K." KEY2 <br /> Mailing Address NDIFFEREIVTfr mFacWAddre" Attention:or Caro Of(ap6wilaq <br /> Mailing Address City .STATE ZIP <br /> SIC CODE APN l y}r ^n 0 �'/ COMMENT: <br /> THIRD PARTY BILLING INFO: Completes if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME /Y 's G )2, � a J =.N C AtterrUan:orCare Of(apbwwo <br /> Mailing Address J'� PHONE Q 'C) <br /> 404 M f>?..I(E`-VGIGTOp.,,IN t�V D G <br /> cin KIN GSC`/ At 1 J STATE Q�Or ote ep sp A 160 <br /> Awavg_q for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> RIIVINE%ND CII\IPLWICs.%k ANOw LtIH.F1rS I 1,the undrreigned Applicant.Certifi that 1 am the On ner.Operator,or.Itnhorfcnl Ag ot.r lhia Ilusineas,and 1 acl.non ledge Thal all 11FRI//F F/rs. <br /> PF�.,iLfir%.Fw lift h.t//:N'/C//-iRt,ts andlor 1101 R/1'C//1Rt,EV a.,1t(iAf d N ith INS Oflera11011 will fie llille d to Idle if the yddre,a identlfled at a a,theilrtlt/'\/jPQRL_\1 for ihm Site. !,41socrrnf.%ihAI <br /> All inrorrnation prosidei on this applitatinn is true and correct:anti that All regulated actisities It ill he performed in accordance with all applicahle IOAQt IN CQl SIN Ord ce Codes and/or <br /> Standards and STA I V,ind/or FEDIfR%L Lawn and Regulalion4 .Its lite undersigned owner,operator.or agent of the l roprrlT located al the abo.e faAcllm/site add res.I hrreyV;tiihoriae the release of <br /> AIM and all rersulm and environmental assessment infornution to C,1V JO.1Qtl IN COUNTY ENVIRONMENTAL IIEALI if OF.I'AK"I>IF:Y FC snow:1c it isle and At the sa^1c rime it i, <br /> prod id hl to n1e or ntr reprecenurisr. <br /> APPLICANT NAME(PLEASE PRINT) �� hf I`�f A{�= NEA U SIGNATURES <br /> TITLETSI # )So'C A??�L\GRCSLE (�ti�pi Q'l c�J <br /> v n E N \f s P--6 W M Ir lam,- 11 <br /> A proved By Date Accounting Once Process( Completed B 1, Date <br /> SITE MITIGATION� AMOUNT PAID DATE,/OF PAYMENT PAYMENT T�YYPPE RErCEIPTT III `r CHECKS RECEIVED BY WORK PLAN PE <br /> FEE:S /� �� I f �1�� 6 C I C�l O2- J W4t!/TE� I_g3iD <br />