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Unchanged since submitted tow'ovember 2012 <br /> San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> IL- SITE MITIGATION&LOP <br /> SHADEDAREAS FOR EHD USE ONLY OWNER IDM CASE UNIT IV <br /> OWNER FILE:COWP1LETE rHEFoctoWNG PROPERTY OWNER/NFoRMArronc CNEClflr OWNER CURRENrtroNrae*YTN EHD <br /> PROPERTY OWNER NAME (209)629-:070(Ask for Sam Franco) <br /> FNS1 111 Last PHONE NUMBER <br /> BUSINESS NAME EMAIL ADDRESS <br /> The Newark Group <br /> Owner Home Address <br /> City STATE ZIP <br /> Owner Mailing Address 2575 Grand Canal Blvd <br /> MalimgAWmxsCtty Stockton state CA Zip 95307 <br /> CORPORATION Q INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OnIER❑ <br /> erre mnxATION_ENVIRONMENTAL ASSMUlNT X VOLUNTARY CLZANUP_wATrx QuALITr_HW PIPEuNe INVliT1oAT1ON_LOP_ <br /> FACIUTY IDM INV# ACCOUNTID ROM ASSIGNED EMPLOYEE LEADAGENcY:EHD_RWQCB X OTSC_EPA_ <br /> /z?0 g qj 6/6 a tj/,V"y <br /> FACILITY FILE COMPLEM THEFOLL01+WNG BUSINESS/FACILITY I SITE/NF0R,IMA)70N. <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No CD <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No Q <br /> BUSINESs1FACIUTYISITE NAME <br /> SITE ADDRESS 800 West Church St ("Dopaco Area"only--see attachment) SUITE# BUSINESSPHONE <br /> Cay STATE ZIP <br /> Stockton CA9520., <br /> BOARD OF SUPERVIsoR DISTRICTG LOCATION CODE 0r KEH KEY2 <br /> Mailing Address I/D/FIeERENT*vm FWMIYAd was Attention:orCare Of(opaorta) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN M COMMENT: <br /> 145-230 .�� <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BuslNEss NAME G A 5 G X'-s f��C S =I V Q Atta"Ition:orCare Of(opEtarissO <br /> Mailing Address 4( M n�E—` ,TC...T�f`jv.ti t t�V � PHONE 8I C) - 3 3 - 5 702 <br /> CITY KIN GSC'-/MA? <br /> - F %-LS 1 STATE qu[6E c -7o A i-6o <br /> AL=1AfrA J ,s9 for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> till I IM.AND Cn,1PLIAN(E \l hPOtt l.l.t//.,1F\1': 1,the Isndersigned 4p1.1i"nt.certih that 1 ant the rhvnlr.Opernlor.or lwlrerrcavl a^111f of Ihia InKI 1 arkrluw ledge fhat all PFN.tIIT 14FI. <br /> PF,:+I f!F_,.r\Ff/Re"Ef/6s!CY!INl.k.s artWor Ifl1!'N/1'C'/l1NI�F.9 assdlinled N ills II&operatlotl,%iii he hilled to Ilse at the addrR4 idirrin ied abo,e YY the',l!Y//::1 reI/111N1%x rpt.Ilin Site. I so ferhl,Y that <br /> all information pro,ided on lhiY appInalllm I%true and correct.and that all refulaied artivilies hill he performed IIs accordance N'ith all applicable SAN.1(IAQt'IN IYII;N l Y Ord' ce t ods+anitror <br /> Standards and SI tfR-drulMr FF DF'R lL 1.a„c and Regulations. As the midesmigried(inner,operator,lir agent of the lsroperh loCalell at IIs!shine faClllt\hilt adtltrss.1 IlerehV i!dltlrl7e tIl!1lleas!UI <br /> am•and all«"nits and entironmentad asse-meat information to SAN J0.Wt1l'4 COUNTY ENVIRONMENTAL IiF..\Ll 11 nEPAR7 NEN ' t conn as it is av>tdabl�d a1 the same lime it is <br /> pro,idtd to nae or ntv repr"enlithe.. <br /> APPLICANT NAME(PLEASE PRINT) L-E<2> r J 1 /M <br /> A P.L NZ-AU SIGNNAATUURRE �'— <br /> TITLE `(v P E N v= �6 W M E Q-i— T— rte �J oi' A 7 L\G A Q(E {C/�htiPpl A t i CQ� <br /> Approved By oat! IT—..U..,OITp PrtmettaiN Comploted By Dale <br /> SITEMITIGATION AMOUNTPAIO DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK* RECEIVED BYw���POE <br /> FEE:Y <br />