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gl San__tp_aquin-County-Environmental-Health-nepartment <br /> DATE M.-a;TER FILE RECORD INFORMATION 'rharRtl GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADEDAREAS BEHDUSEONLYOWNERID# CASE# UNIT IV <br /> OWNERFILE : COMPLE7F7HEFOLLOWNGPROPERTY OWN ER /NFORMATJON.' CHECK/F OWNER CURRENnroNF/LEW/rHEHD �x <br /> PROPERIYOWNER NAME Min Le (408) 893-1418 <br /> First MI Last PHONE NUMBER <br /> BUSINESSNAME McBillin Real Estate Investment E-MAILADDRESS <br /> mle@amac1 .com <br /> Owner Home Address 3087 Oldwood Court <br /> city San Jose STATECAZIP 95122 <br /> Owner Mailing Address 3087 Oldworld Court <br /> Mailing Address City San Jose Dry state CA 7P 95122 <br /> CORPORATION ❑ INDIVIDUAL ❑ PARTNERSHIP FEDAGENCY ❑ OTHER ❑ <br /> SITE MITIGATION _ ENVIRONMENTAL ASSESSMENT _ VOLUNTARY CLEANUP _ WATER QUALITY _ HW PIPELINE INVESTIGATION _ LOP X <br /> FACILITY ID # INV# ACCOUNTID PR #IRO # ASSIGNEDEMPLOYEE LEAD AGENCY: EHDRWQCB _ DTSC _ EPA _ <br /> r�tfs � ! (�v 1r94 -7 Vic /< I <br /> FACILITY FILE COMPLETE THEFOLLOW/NG BUSINESS / FACILITY / SITE AfFORMAT/ON: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes ❑ No FLI <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YEs ❑ NO 0 <br /> BUSINESWFACIUTYISITENAME McBillin Property <br /> SITEADDRESS 2154 S. EI Dorado St SUITE# BUSINEWPHONE <br /> na <br /> CITY Stockton STATE ZIP <br /> / CA <br /> SOARDOFSUPERVISOR DISTRICT LOCAnONCOOE / KEY1 KEY2 <br /> Mailing Address NO/FFERENTfnam Fact iii1yAddress Attention: orCare Of topNonafJ <br /> i <br /> Melling Address City STATE ZIP <br /> SIC CODE APV # ' COMMENT: <br /> X47 - a5� � z <br /> THIRD PARTY BILLING INFO: Complate if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Advanced Geo Environmental, Inc. Attention: orCare Of lnpffmau# <br /> Meiling Address PHONE <br /> 837 Shaw Road 209-467-1006 <br /> CITY <br /> Stockton STATE CA ZIP 95215 <br /> AccouNTADaats_e for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> IIMLTNGAND COMPLIANCE ACXNOWLMGMENT: 1, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and I acknowledge that all PERnm'FErs, <br /> PENn =s, Erveoacl: EwCannoes and/or HOURLTCH GES associated with this operation will be billed tome at the address idenfified above as theACc MTAnnrsEcr for this site. I also certify that <br /> all information provided on this application is true and correct, and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIINCOUN'IY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner, operator, or agent of the property located at the above faciity/site address, l hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME (PLEASE PRINT) TIMOTHY J. CUELLAR SIGNATURE JU" I <br /> TITLE PROJECT MANAGER TA% ID # <br /> Approved By Date Accounting Office Processing Completed By Date <br /> SITE $MITI ON AMOUNT PAID DATE OF PAYMEM PAYMENT TYPE RECEIPT CHECK # REC€INFO BV WOR PLANPE <br /> FEE: ICY/J{ r�Jl JTc/aJ,� <br />