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San Jo--uin County Environmental Healthartment <br /> DATE MAa fER FILE RECORD INFORMATION ClAr" GREEN FORM <br /> II-21-12 <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# S qco(,(, 1/ / UNIT IV <br /> OWNER FILE:COMPLETE 7HEFOLLOWING PROPERTY OWNER/NFORMArlow CHIEcKC/F(OWNER CuRRExn.YoAfFxE*nN EHD <br /> PROPERTY OmER NAME ( ) <br /> rjr_nr-ij jr- <br /> First Ml Last PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> SAN JOAQUIN VALLEY ASSOCIATES NOV 1 01 <br /> Owner Home Address <br /> 24012 CALLE DE LA PLATA #460 <br /> CRY LAGUNA HILLS STATECA zPERK�S§F3RVICES <br /> Owner Mailing Address 24012 CALLE DE LA PLATA#460 <br /> Melling Address City LAGUNA HILLS state CA Zip 92653 <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP IDI FED AGENCY❑ OTHER❑ <br /> SITE MMOATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INV# ACCOUNT ID PR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD 4. RWQCB_DTSC_EPA_ <br /> Ozlgj 1 11 33`�� '( ( ,0v 5.111 o (�(�53�51 Jo ratitiy <br /> FACILITY FILE COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE/NFORMAT/ m <br /> Is this a NEW Business LOCATION not previously regulated by the ENvIRONMENTAL HEALTH DEPARTMENT? YES [ No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No C <br /> BUSINESS/FACILmISITENAME SAN JOAQUIN VALLEY ASSOCIATES <br /> SITE ADDRESS 1810 SOUTH FRESNO AVENUE APN 163-820-65 SUITE# BUSINESS PHONE <br /> CITY STOCKTON STATE Cep 95206 <br /> BOARD OF SUPERVISOR DISTRICT / LOCATION CODE I KEY1 KEY2 <br /> Mailing Address/fD/FFEREATfrom Fac//KyAddrew Attention:orCare Of(optJonaQ <br /> Mailing Address City STATE LP <br /> [!ff: <br /> 11AP :J N# COMMENT: <br /> 14 3-�2v -G S <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME SBS PACIFIC PROPERTIES Attention:-care of(opavna)BABU SAGIREDDY <br /> Mailing Address 1801 EAST MARCH LANE, SUITE B-265 PHONE <br /> Cm STOCKTON STATE CA 7jP 95210 <br /> AccomvrADDREss for fees and charges OWNER FACILITY/BUSINESS DARTY <br /> liut.nr, \�D('untNl.tsa(t.:\lt:N(mt,t:ue\t:��: I,the undersigned \pplicant,certil'c Ih:rt I:un the On•ner,Ilperuna,or.lndnn•i:rd.-hrnl of this Business,and 1 acknowledge that all Neevnli:7r.`. <br /> Prc u.nlrv.1i\FOR(Tl11:\7 0/ and/or Hol R1.1(11IRGEA associated kith this operation will be billed to me at the address identified above as the,N(ou\7.4DDRF_SS for this site. 1 also certify that <br /> all information provided on this application is true and correct:and that all regulated activities kill be performed in accordance kith all applicable S\N JO.AQtaN COt,NII Ordinance Codes and/or <br /> Standards and Sr cit and/or VIA)FIR U Laws and Regulations. As the undersigned owner,operator,or agent of the propert.located at the above facilit)Ysite address.I herebN authorize the release of <br /> anand all results and ertviromnental assessment information to SAN JOAQUIN COUNI'Y VN\'IRONNIEN1%I. HEALTH DEPARTNIENT as soon as it is available and at the same fine it is <br /> provided to me or in representative. NbIN,9rcasrr.e.w=dy <br /> APPLICANT NAME(PLEASE PRINT) DR. P. BABU SAGIREDDY SIGNATURE <br /> .nnE TAX ID# <br /> SBS PACIFIC PROPERTIES <br /> Approved By Date Accounting Office Processing Completed By Date <br /> SITE!MITIGATION AMOUNT PAID DATE PAAYMENT PAYM�IENT TYPE RECEIPT# C CK# RECEIVED BY WORK PLAN PE <br /> FEE:! ?7� 375 I I —� I`(Z C' ( K ���� t -6 <br />