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San Joaquin County Environmental Health Department <br /> cc » GREEN FORM <br /> DATE 1/25/2011 MASTER FILE RECORD INFORMATION MFR SITE MITIGATION&LOP <br /> TSHADED AREAS FOR EHD USE ONLY OWNERID# <br /> CASE IS SR�4S3y'� UNIT IV <br /> CHECritF OWNER CURR&.-ayoHFILEWITH EHD <br /> OWNER FILE:COMPLETE THEFOLLOW/NG PROPERTY OWNER INFORMATION: <br /> (209) 629-5070 (Ask for Sam Franco) , <br /> PROPERTY OWNER NAME <br /> First <br /> MI Last PHONE NUMBER <br /> E-MAILAODRESS <br /> BUSINESS NAME The Newark Group <br /> owner Home Address <br /> STATE ZIP <br /> City <br /> owner Mailing Address 2575 Grand Canal Blvd <br /> Mailing Address City Stockton State CA vP 95207 <br /> CORPORATION El INDIVIDUAL❑ <br /> PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE�rR6ATlON_@PIVtRONRIENTAL ASSESSMENT X VOLUNTARY CLEANUP WATER QUALITY HW PIPELINE INYE57 aATION LOP <br /> FACILITY ID# {WV# ACCOUWS ID PR#JRO# -ASSIGNED.EMPLOYEE LEAD AGENCY Ell <br /> - RWQCB DTSQ <br /> kc &Ct <br /> FACILITY FILE COMPLETE THEFOLLOWING BUSINESS/FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LocaTloN not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES YNo <br /> ❑ No <br /> iS hi:an EXISTING Business LOCATION but a NEW TYPE of regulated Business? <br /> Es ❑ ® ' <br /> BUSINEsstFACIUTY/SITE NAME <br /> SUITE# BUSINESSPI40NE <br /> SITEADDREss 800 West Church St <br /> STATE ZIP <br /> CITY Stockton CA 95203 <br /> t KEY2 <br /> BOARD OF SUPERVISOR DISTRICT LOCATIONCOOE 1 KEr1 , <br /> Mailing Address JfD/FFERENTfromFec11dyAddrass 111 Attention:arGare of(optcrne/) <br /> STATE 21P <br /> Mailing Address City <br /> SAPN# COMMENT: <br /> IC CODE <br /> 145-23 0 <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFacility Operator identified above. <br /> Attention:orCareOf(1pt1bna/J Richard Scanlan <br /> BUSINESSNAME Dopaco, Inc <br /> PHONE (484)875-3760 <br /> Mailing Address 100 Arrandale Blvd <br /> CITY STATE PA zip19341 <br /> Exton Email: Rick.Scanlan@Dopaco.com <br /> ArroUHTAODREss for fees and charges <br /> OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKC\OWLEDGAfER C: 1,the undersigned Applicant,certify that I am the Olvner,Operator,or Anthor!�d Agent of this Business,and I acimowledge that all PEMIIT FR , <br /> Fs <br /> PENALTIES,ENFORCEAtEM'CHARCES and/or JJOURLyCHARGES associated with this operation will be billed to me at the address identified above as the ACCOVATADDRESS for this site I also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JoAQtma COUNTY Ordinance Codes and/or <br /> 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[hereby authorize the release of <br /> any and all results and environmental assessment information to S.AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH llEP TMENf as soon as it s a 8ilahle and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) Richard J. Scanlan SIGNATURE <br /> :FAX to -3=2106 8 <br /> TITLE Sr, VP Finance, Dopaco, Inc. y 1 <br /> Accounting Office Processing Completed By ." Date <br /> ApprovedBy Date " <br /> RECEIVED BY WORK PLAN PE <br /> SITEMITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# <br /> FEE: 40 .`O <br />