BILLING - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Dc, ARTMENT DATE March 19,2014 MASTER FILE RECORD INFORMATION"MFR" GREENFORM 11 SITE MITIGATION&LOP SHADED AREAS FOR EHO USE ONLY OWNER ID# CASE# UNIT IV OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNERS CURRENTL Y ON FILE W7TH EMD El PROPERTY OWNER NAME Port of Stockton (209)946-0246 FIRST MI LAST PHONE NUMBER BUSINESS NAME Port of Stockton E-MAILADDRESS OWNER HOME ADDRESS 2201 W.Washington St. CITY Stockton STATE CA ZIP 95203 OWNER MAILING ADDRESS 2201 W.Washington St. MAILING ADDRESS CITY Stockton STATE CA ZIP 95203 ®CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION_ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY X HW PIPELINE INVESTIGATION_LOP FACILITY ID# INV# AccoUNT ID PR#1 RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB_OTSC_EPA 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 Co No ❑ BUSINESSIFACILITYISITE/PROJECT NAME UP Welding Facility, Landfill Areas, RRI SITE ADDRESS/PROJECT LOCATION Shipley Road at Humphreys Dr. SUITE# BUSINESS PHONE CITY Stockton STATE CA zip 95203 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS 2201 W.Washington St. ATTENTION:ORCARE OF(OP770NAL) MAILING ADDRESS CITY Stockton STATE CA ZJP 95203 [!tE APN# COMMENT: THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME ERS Corp ATTENTION:ORCARE OF (OPTIONAL) MAILING ADDRESS PHONE 925-938-1600 1600 Riviera Ave Suite 310 CITY Walnut Creek STATE CA ZIP 94596 ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING® BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the(honer,Operator,Authorized Agent,or Respoicvible Part),and 1 acknowledge that all PER,1117'/'EES, PENALTIES,ENFORCEMEN'TCHARGES and/or HOURLYC77ARGE.S associated with this project will be billed tome at the address identified above as the ACCOUNTAI)ORESS'for this site. 1 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 JO.AQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned(honer,Operator,Authorized Agent,or Responsible PurV for the project located above under facility/site address,1 hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JO.AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. APPLICANT NAME(PLEASE PRINT) Leslie Shields,ERS Corp SIGNATURE TITLE Project Scientist TAxID# 36-4459849 APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE D BY WORK PLAN PE SITE MITIGATION AMOUNT PAID DATE OF PAYME:T ] P AYMENT TYPE RECEIPT# CHECK# RECEIVE FEE: