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Unchanged since submittecNOW dovember 2012 �..t <br /> San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADED AREAS FOR EHD UsE ONLY OWNER ID# CASES SRooG 7638 UNIT IV <br /> OVMNER FILE:COMPtM rHEFOLLOWNG PROPERTY OWNER/NFORMArION.• C#(rcArri OWNER CuporemnroN Faz*(rH EHD 0 <br /> PROPERTY OWNER NAME (209)629-4470(Ask for Sain Fra <br /> Iry ,N( Last PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> The Newark Group <br /> OMRIer Home Address <br /> City STATE Zip <br /> Owner Mailing Address 2575 Grand Canal Blvd <br /> Mailing Address City Stockton State CA vP 95207 <br /> CORPORATION© INDMDUAL❑ PARTNERSHIP❑ FED ADENCY❑ OTHER❑ <br /> Srm Mfn"T1oN_ENVIRONmEwAL AsseamENT X VoLuNTAnY CLPANUP_WATER QuALITY_HW PIPELINE INvesnaAnoN_LOP_ <br /> FACIUTYID# IHV# ACCOUNTIO I ROK Asm"EDEMPLOYEE LEAD AGENCY-.EHD_RWQCB Y DTSC_EPA <br /> 117oa ARcozl12, P w <br /> FACILITY FILE CoMmPLE,E rHEFouo*wNG BUSINESS/FACILITY/SITE IA(FoRM4770,V., <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT1' YES ❑ No p <br /> IS this an EXISTING Business LOCATION btA a NEW TYPE Of regulated Business? YES ❑ Nc <br /> 8UsIN"sfflACILIYY1SrtE NAME <br /> SITEADDRESS 800 West Church St ("Dopaco Area"only--See attachment) SUITE# BUSINESS PHONE <br /> Cm Stockton STATE ZIP 5205 <br /> BOARD OF SUPERVISOR DISTRICT 101 LOCATION CODE O i KEY1 KEY2 <br /> MallkV Address drO1FFFREAfrblon(F&cWryAakfresa Attention:orCare Of(optional <br /> M"MingAddress Cky STATE zip <br /> SIC CODE APN# COMMENT: <br /> 1 x,15,230-Q 4' <br /> THIRD PARTY BILLING INFO: Complete if Billing Party Is different from Property Owner orFacility Operator identified above. <br /> BUSINESS NAME A .S G A iJ C S T—� ,Q Attention:orCare Of(opolw>ta / <br /> Melling Address 404 M A?I E- V I C--TO RiN F�A—V � PHONE (�I Q�! 3\G 3 702 <br /> Cmc KIN G S C1/ 1_� s STATE AUG LI`C21P 0-0 A 160 <br /> AccouAnrgilnag ss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> ILII I I\I:ICD Cn\IeI,tA1(E \i tino"t(n4ilrs r: I,the—Jr—sped Applicant.certih prat I am the(#ince,(Jfrrrnh.r,or Ic rhmicn(-0genf of Ihia Ru>inn>,nnJ I arlvlu"led Re that w11 PFA1IfT Fre-�. <br /> Pcvo m%.FAPI/R(Lr1Lnl CII tRb6A and!or(MLIO I'C/I1BaF.4 as.Aucialed"ith this operation"ill be billet to nit at the address identified abose as the 11 uN\f-Ifor Ihis site. V-cerhfv that <br /> all information provided on Ihii appliralinn it Inde and correm and that all regulated artivilin Bill lie performed in accordance with all applicable SAN J0AQI IN('01;441 Y Ortipia6ce Cod"Andfor <br /> Standards and%r%rF and/or FF DI(R IL I A"s and Regulatinns. A.v she undersigned o"tier,operator.or agent of the pruperty located in the shin a facdlh Nile Addreas.I hrrcbvm ihorve the releaw of <br /> any and 211 results and en0ronmrutrl:uae"ment information In SAN JQ.IQI IN COUNTY ENVIRONAIEN'I'Al.IIF.A1.1 H DE PAR VIE S x"m ai it I.,ave_Jabl a d At the Seale time it is <br /> proAidel tome nr mY reprrcenmrise <br /> APPLICANT NAME(PLEASE PRINT) L C c) T-j ' ! A R,L N E A U SIGNATURE / � <br /> TITLE y j7 E Q T <br /> rT�xI # iso; A?�L\GAP�LE {CAI Ol�►I Cp� <br /> A ve <br /> rod By Me Accounting Otru Prxaaal Completed R Oat. <br /> SITEM171GATION AMOUNTPAID DATE OF PAYMENT PAYMENTTYPE RECEIPTS CHECKS RECEIVED BY WORK PUN PE <br /> FEE: <br />