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San Jou quin County Environmental Health Department <br /> GREEN FORM <br /> DATE MASTER FILE:RECORD INFORMATION `lMFRrr <br /> IOWNER ID# s� s CASE At"� UNIT IV <br /> OWNER FILE <br /> CHEcKiF OWNER CURREWLYONME wrm EMD ❑ <br /> L COMpLETETHFFOLLOWINGP OPE TY OWNERiTNFORHATION: <br /> PRDPERIYOwNERNArnE Marge Comer. PHONE (209)985-14S <br /> Flrsf Mf Last }� <br /> i <br /> I SUSINESS NAME Swift Roofing Soc SEc/TAX ID# <br /> OwnerHotneAddtess 4639 Ridgewood Court DRvERsUcENSE# <br /> Citv Stockton STATE CA zw 95212 <br /> Owner Mailing Address Same <br /> j <br /> f <br /> Mailing Address City State Zip <br /> I zONK <br /> i <br /> CORPORATION❑ INDIVIDUAL C PARTNERSMP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FAaLISY SD# CRSS REF ID# ACCONT ID#U <br /> � INY# <br /> COMPLE7F THE G BUSINESS 11 TE&MMani• <br /> Is this a NEw Business LOCATION not Previousty regulated by the ENVIRONMENTAL HEALtH DEPARTMENT? YEG ❑ No l* <br /> r Is this an EXISTING Business LOCATIPN but a NEw TYPE of regulated Business? Yes ❑ No 1:3 <br /> SUSVIEss/FACUTY/SITE NAME Swift Roof i <br /> j <br /> SITE ADDRESS 1930 West Fremont Street SMM# BUSMESSPHONE <br /> CITY Stockton STATE CA Zip 95215 <br /> t <br /> x <br /> BOARD OF SUPERVISOR DLgVM LOMTM CODE KE1 t KEYS , <br /> f Maging Address lfDIFFFRENTfrvm Fadll[y"dress Attention:or Care Of(optional) <br /> Mailing Andress Clay STATE ZIP <br /> SIC Coot APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BusViEssNAf!a Attention:orCare Of(optional) <br /> 1 Advanced GeoEnvironmental, Inc. <br /> f MallitTgAtidTess 837 Shaw Road PHoA (209) 467-1006 <br /> CITY Stockton STATe CA Ztf' 95215 <br /> r <br /> for fees and charges OWNER FACILITYBusINESS IRD PARTY BILLIN <br /> i <br /> nn.LINC ANm rn NYLSANt 6 AC RNnwtrDrwMNT: 1,the undersigned'Appiiamt,certify that lain the Oamer,OpvWor,or Anthorked Agent of this Business,and I acknowledge that allPF•RW FW, <br /> PENALTIM,ENFORCEMENT CHARGM and/or BOURLYCRARGE4associated with Obis operation will be billed tome at the address identified above as the Ancomff nntrFce 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 perfbvmed in accordancewith all applicable SAN JOAQM COUNTY Ordinance Codes and/or <br /> 1 Standards and STAIR and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,oragent of the property located at the above facility! to address,I hereby authorize the release of <br /> any and all results and environmental nssessn cal Imformatiou to SAN JOAQUIN COUNTY ENVIItON?dENTAL HEALTH DEPART ass ble and at the same time it is <br /> provided to me or my representatives <br /> APPLICANT NAME Robert Marty PLEA'EPRxNt SIGNATURE '71, <br /> AN <br /> r s TITLE Vice President / Advanced GeoEnvironmental., Inc, 'DRIVER'SLICE SE# <br /> .(PHOT000PY REDuiRED) <br /> Approved By Date Accounting Offke Ptacrssimg Completed BY (7. Da[@ <br /> 29-02.002 April 25,20D3 :; <br />