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Unchanged since submitted�lovember 2012 Nft./ <br /> San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADED ARFAsfoR EHO Dee ONLY OWNER IDs CASE# UNIT IV <br /> OIf11NERFILE:CoArPrLE71EMEFOLLO 7NG PROPERTY OWNER/NfmM,47t w CNEcwAI,OWNER CupeEnnrwiFazmrstEno 0 <br /> PROPERTY OWNER NAME (209)629-1070(Ask for Cann Fral1C01 <br /> First Ht Last PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> The Newark Group <br /> Owner Home Address <br /> City STATE ZIP <br /> Owner Mailing Address 2575 Grand Canal Blvd <br /> MalllMMdreesCity Stockton state CA ZIP 95307 <br /> CORPORATION ID INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> Srm Mm"TfoN_ENYIRONML'NTAL AssnaunwT X VOLUNTARY CLMNOV_WATIHR Qumny J HW PIrlume(NV!= awri0N_LOP_ <br /> FAuuTr 10 0 INV♦II ACCOUNT ID PR III RO t1 [-A"K;NED EMPLOYEE LEAD AGENCY:EHD_RWQCB_DTSC_EPA_ <br /> FACILITY FILE CowwrE7HEFottowsvo BUSINESS/FACILITY SITE INfoRailrlom <br /> Is this a NEW Business LOCA nON not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No D <br /> Is this an E%IsTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> SUsikESSIFACILITYfSrTE NAME <br /> SrrEAmpess 800 West Church St ("Dopaco Area"only--see attachment) SUTES BUSINESSPHONE <br /> CISTATE ZIP <br /> CITY Stockton A 95203 <br /> Stockton <br /> BOARD Of SUPERVISOR DISTRICT LOCATION CODE KEY1 KEI'1 <br /> MaOkfg Arddreu MOJFFFREAFr*owFicW[yAddiem Attention:or Cam Of(apeterlr/J <br /> Mailkfg Addres"City STATE ZIP <br /> SIC CODE APN A COMMENT: <br /> THIRD TARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME A G ACZNC. <br /> Attention:orCara Of(oprtd)No <br /> G s RS . <br /> Mail"Address 40A <br /> M A?.IE—V.TC_TOR.iN Civ 1�, -t-P"°"E 8I C) 5 702 <br /> CITY KT N G S C`/ '�-- N►_1_S STATE QQC A I-e'p ZrO A 1.60 <br /> Afor fees and charges OWNER FAcILITYIBUSINESS THIRD PARTY BILLING <br /> Du t nc»n Costrs_t.\�t L LCh!sOW Lk11f.\IF.\I': I,she undenignrvl pplicanr.certify that 1."I the ehrmr.Qprraiw,or,tnilrnric&I aster of this Uoo-insss.poli I sitrknow ledge that 411 PFii.tit r FF Fs, <br /> PE s'ti AF\.r\FtIRt'Lail,Yi L'Ii INbk.\andlar Haviii I'C&Ide.`'c aLssouatcd"ills this opera lion n ill he billed to me at the address identified Ono e in the At t rir:y-11.11FC4P for Ihis site. 1.141so eerh(e that <br /> all information presided on Ibis application is true and correet::md that till rtYudated activities Nill Ise performed in accordance with all applicable IOAQI'.IN fYH;V7Y OrdlitsirlFcc Codes anrl.lor <br /> SIandards.tnd%r%ry andl(tr Ff DCR\L I.I%s itnd RNulatintls. As the ilndomigned oN Iter,operator.or sigent of the proper/}located at the abvnt faCl`It)Aile address.I hereby ik dlot'V.e the release of <br /> any and all results and en\ironmen wl assessment information to SAN J0.11QIIIN COIi\TV EN VIRONNIF.NTA 1.tIF.A1,1 H 1)1.PAR'I vIEYI�rS 'oon as it ss avada4l;1nd at the same time it is <br /> provided to me or mss repreaenlaHce. <br /> APPLICANT NAME(PLEASE PRINT) L Ec> tom! M A P,= N E'A O SnMATURE <br /> TITLE P E N V Z f2 c5 N M E Q T' T4x4Ef- c0) <br /> Approved Sy Dab Aswan.. Ogee Proceset Corsspleted By Date <br /> SITEMITIGATION AMOUNTPAIO DATE OF PAYMENT PAYMENT TYPE ECEIPTS RTHECKiti --TECEIVEDBY WORK PLAN PE <br /> FEE: <br />