FIELD DOCUMENTS FILE 2 - Laserfiche WebLink

Home Browse Search

DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM SITE MITIGATION& LOP SHADED AREAS FOR END USE ONLY OWIM IDLY CASE b � UNIT IV OWNER FILE:COMPLETE PROPERLY OWNER/RESPONSIBLE PARTY II1IFORMA7I0N.• CMWKAF OWNER CURRENTLY ON RLE WITH EHD PROPERTY OWNER NAME Allen L• Genetti (20: 466-3554 First MI Last PHONE NUMBER BUSINESS NAME Cal Tank Lines, Inc. E-MAILADDRESS Owner Home Address 3105 S. El Dorado St. city Stockton STAT A z"' 95206 Owner Mailing Address 3105 S. El Dorado St. Stockton, CA 95206 l Mmnng Address City 3105 S. El Dorado St. Stockton s��A 7JP 95206 -- CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSISLE PARTY ❑OTHER SITE MITIGATION_ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP X FACILI'T-ID 0 INV# ACCOUNT ID PR Irl RO ASSIGNED EMPLOYEE j l EAo AGENCY:EHD.__RWQCB_DTSC_EPA__T 1Akcc#1,v - FACILITY FILE: COMPLETE BUSINESS/SITE/PROJECT INFORMATION: Is this a NEw Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No Is this an EXISTING Project LOCATION but a NEW SCOPE OF WORK? YEs I�1 No ❑ BusiNESSIfACILITYISITEIPROJECT NAME Cal Tank Lines,Inc. Sn-E ADDRESS/PROJEOT LOCATION SUITE III BUSINESS PHONE 3105 S. El Dorado Street cRY Stockton _ CA 95206 I BOARD OF SUPERVISOR DISTRICT ' LOCATION CODE KEY'{ I KEPT. I d Melling Address ND1FFERENTfromFec111tyAddress Attention:orCare Of(opffonai) Mailing Address City STATE zip ft APN I COMMENT: �l7 -I20-oZ$ THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Responsible Party identified above. BUSINESS NAME l 1 _ Attention:orOare Of(optional) �VAJ AiJ7 ,) L� w" Mailing Address�. � .� 1� >� PH ONE CITY l STATE LP UiSt-c� C %Z, S �QGOtJAtZS for fees and charges OWNER FACILIIY/BuSINESS THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Apphcant,certify that I am the Owner,Operator,Authorized Agent,or Responsible Party and I acknowledge that all PERMIT FEES, PFNAi nFs,FW0RCFMFx7 CHARGEsanolDr Heusi YCHA.RrEs assuctated with this proje.t will be billed to me at'he address identified above as the ACCOUNT ADDRESS for this site. I also certify that all information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN JCAOUIN COLIN"Y Ordinance Codes and/or Standards any STATE and/or FEDERAL Laws and Regulations. As the undersigned Owner,Operator,Authcrized Agent,or Responsible Party for the project located above under facility/site address,I hereby authorize the release of any and all reswts,reports,and other environmental assessment Wormation to SAN JOAQU IN COUNT Y VIRONMENTALHEALTH DEPARTMEN(assoonasit is available and at the same time It is provided to me or my representative. APPLICANT NAME(PLEASEPRINT) Anderson M. Dorian (Agent) SIGNATURE I'fLE General Manager TAX ID* Approved By Date Accounting Office Processing Completed By Date li SITE MITITIG ION AMOUNT PAID DATE Or PAYMENT PAYL:ENT TYPE RECEIPT# k RECFIVED BY WORK PLAN PEFEE:$ _ _ � 3 �_J [CHECK