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San 0quin County Environmental Health Alartment <br /> DATE 11 03 April 2015 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION &LOP <br /> aKD ASa HD USE QNLY OWNER IDS CASE# UNIT IV <br /> OWNER FILE:CoAfPLETEPROPERTYOWNER!RESPONSIBLE PARTY/NFORMAnoN: CNECKIFOWNER CURRENTLYONFKEW?NEHD � <br /> PROPERTY OWNER NAME Alan R coon <br /> ( 209) 996-9615 <br /> First MI Last PHONE NUMBER <br /> BUSINESS NAME E-MAILADDRESS <br /> Delta Parma Reclamation District 2029 ®arcoonlaw.com <br /> Owner Home Address 421 South El Dorado Street, aerie E <br /> City STATE Ztv <br /> Stackton 0A 95203 <br /> Omer Melling Address same as above <br /> Mailing Address City State Zip <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY O RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP WATER QUALITY HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INV# ACCOUNTID PR#I RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCS-X- <br /> FACILITY EPA_ <br /> /� xT r347l� Ro ( /32 /OrYA 0v <br /> FACILITY FILE: COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No El <br /> Is this an EXISTING Project LOCATION but a NEW SCOPE OF WORK? YES © No ❑ <br /> BUSINESSIFAOILDYISREIP0.0JECTNAME .Canso s Helena Marina <br /> SITE ADDRESS/PROJECT LOCATION SURE# BUSINESS PHONE <br /> 15135 Eight Mile Road 209-946-9675 <br /> CRY STATE LP <br /> Stockton CA 95203 <br /> BOARD OF SUPERVISOR DISTRICT O LOCATION CODE r KEY1 KEY2 <br /> Melling Address MDYFFERENTdom FadlllyAddreas Attention:or Care Of(opflonal) <br /> 421 South E1 Dorado Street Suice E Alan men <br /> MailingtArWresa City STATE ZIP <br /> CA 95203 <br /> SIC CODE APN#__��_Q�,�� COMMENT: <br /> THIRD PART'1/BILLING INFO: Complete if Billing Party is different from Property Owner or Responsible Party,identifiedabove. <br /> BUSINESS NAME Attention:OrCere Of (optional/ <br /> Advanced GecEnvironmental Inc. Robert Marty <br /> Melling Address RHONE <br /> 209-469-1006 <br /> aJ] Shaw Road <br /> Cm STATE LP <br /> Stockton CA 95215 <br /> AcominrAfor fees and Charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE_ACKNOWLEDGMENT: I,the undemigned Applicant,Certify that I am Rhe them,Operefor Authorized Agent,Or ResponsWe Par y and I aclmOWledge that all PERMIT FEEL <br /> P£hALTIES,ENFORCEMENT CHARGES and/or HOGRLYCHAIWACS associated vith this project Will be billed to me at the address identified above as the ACYyRMTADDRESS for this Site. I also certify that all <br /> information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FCDEML laws and Regulatiom. AS the undersigned Owner,Operator,Authorized Agent or Responsible Party for the project located above under facility/sire address,I <br /> hereby authorize the release of any and all Dennis,reports,and other envimnmenal asshssment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT'm Soon as it <br /> is mailable and at the same time it is provided to Me or my rep�enmfive. <br /> APPLICANT NAME(PLEASE PRINT) Robert Marty SIGNATURE <br /> TITLE President TAKID# <br /> Approved By aii V OM.PrmeeNhp Consialsdaml B Deb <br /> SRE MRTIGATION AM�OjUNpT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CNECKk RECEIVED BY WORK PLAY PE <br /> FEE:$ ?6 J /O ��3'IS Clc�+k — IIL(2'2— CToctWT-a:Q 6CJ <br />