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Unchanged since submitted'ovember 2012 <br /> San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> $ITE MITIGATION&LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER IDR CASED UNIT IV <br /> OWNER FI LE:COMPLETETHEFOLLOW/NGPRO PERTYOWN ERINFORMArtom CkroxrrOWNER CuRwfxrcravFrcEWrHEND 0 <br /> PROPERTY OWNER NAME (209)629-5070(Ask for Sam Franco) <br /> First Ml Last PHONE NUMBER <br /> BUSINESS NAME EaaAti.ADDRESS <br /> The Newark Group <br /> Owner Homs Address <br /> City STATE ZIP <br /> Owner Moiling Address 2575 Grand Canal Blvd <br /> Mailing Address Coy Stockton State CA zip 95207 <br /> CORPORATION Q INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> Srro MrriaA,noN_ENVIRONmnwAL AssessMew X VOLUNTARY CLCANUP_WATER QUALITY—HW PIPELINE INVEMOATTON_LOP— <br /> I <br /> FACILITY IDR INVR ACCOUNTID PROIRON 1ASSIGNEDEMP LoYEE I LEAD AGENCY:EHD_RWQCB_DTSC_EPA_ <br /> FACILITY FILE COMPLETETHEFOLLOWNG BUSINESS I FACILITY SITE/NFORMA17ON.' <br /> Is this a NEW Business LocATON not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an ExisTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESSWACILITY/SITE NAME <br /> SITE ADDRESS 800 West Church St ("Dopaco Area"only--see attachment) SUITE BUSINCSSPI40ME <br /> CITY STATE ZIP <br /> Stockton CA 9520; <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Malling Address M0IFFERENrfr0m FacWlyAddross Attention:orCaTe Of(q AWwQ <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN R COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Patty is different from Property Owner orFacility Operator identified above. <br /> SUSINEss NAMEAsc. A �CzNcAttention:orCere Of(Optra <br /> dOQ <br /> � S . <br /> Mailing Address 40 1 M A?_1F_-VIC_T01ZI,N f V D PHONE 8l q - 3�^t3 • 5/702 <br /> CtrY Kz N GSC`/ A L-L- STATE QOG&e e" -J 0 A 160 <br /> for fees and charges OWNER FACILITY/BUSINESS ` THIRD PARTY BILLING <br /> !dn tTSCyVD('ogeLLs�cu:A[x�Uw LFnr,vsn.0 I': 1,the undrnignal Applicant,certify that 1 as the Onne,.(1peroa.r,or Irnknrkct1Agen(uf this Ifwiness,and 1 arhnowledge thal all 11rRtur Fe F'.c, <br /> PFV.i1.11F_%.r%FO Re'IOMN'1 0/401,tS and/or IItPUR1 V011R1:ES associated w ilh this opera lion Hill be billed to on,at the address identified above as the dr a rHAl,I1V+Rt:Cs'for this cite. 1, .o certify that <br /> all information provided on this application in trete and correct:and that all regulated activities kill be performed in accordance with all applicable%AN JOAQI IN(SOI NI Y Ord' ce Codes andfor <br /> Standards and St%I E andlor FFUFR 1L Laws and Regulatimts, As the undersigned owner,operator,or ao„ent of the pruperh located at the abase fardoAite add ress,i hereprauihetve the release of <br /> any and all results and environmental assevvment inftrnution to SAN JOAQt,IN COUNT FN%'iRON1IF.NTA 1,11F,A1,111 Of,PA V!:VJ' corm as it is Sand at the sanw time it is <br /> pros ided to nu or m representative. (�� T <br /> APPLICANT NAME(PLEASE PRINT) LEO IBJ 1 ( A P—r N E A U SIGNATURE <br /> TITLE f P E Ny Z R c5 N M t�J`T-" T # <br /> Aroved sy Onto Ae,,t, ng ice Pronesstng Completed By Onto <br /> SITE MITIGATION AMOUNTPAID DATE OF PAYMENT PAYMENTTYPE RECEIPTIf CHECK* RECEIVED BY WORK PUN PE <br /> FEE:$ <br />