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San Jo An County Environmental Health C Irtment <br /> DATE February 22, 2011 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> s ND SITE MITIGATION & LOP <br /> �� GNfI�"I°" DAB°' UNIT IV <br /> OWNER FILC:COMPLETE TNEFOLLOW/NUs PROPERTY OWNER INFORMATION.' CNlCa/i <br /> P <br /> ROPERTYAME Calpine Containers, Inc. OWNER CURRENIIYON F2EW/rn END ❑ <br /> FNaf MI Lost PNDNE NUMBER (559)519-7179 <br /> Calpine Containers, Inc. "AILADDREBB <br /> mee ksommers@calpinecontainers.com <br /> rese 9499 North Fort Washington, Suite 103 <br /> Melling Address City <br /> Fresno State CA Zip 93730 <br /> CORPORAT ON;K INDIVIDUAL 11 <br /> Acs PARTNERSHIP El <br /> ` PED AGENCY❑ OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALJTY_HW PIPELINE INVESTIGATION_LOP_ <br /> FACILITY IDA INV# Account ID <br /> PR IN RO# ' <br /> eH�„=.+�vcoa <br /> FACILITYFILE COMPLETE THE FOLLOWNOBUSINESS/FACILITY/SITE/NFoRmA77oN: � <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 I$ <br /> BUSINES51FACILITYISITENAME Calpine Containers, Inc. <br /> SITEADDRESS 1301 East Lockeford Street SUITE BUSINESS PHONE <br /> (209)334-0330 <br /> CITY Lodi STATE Lv <br /> CA 95240 <br /> BOARD OF SUPERVISORDISTRICT k LOCATION CODE KEY1 KEY2 <br /> Melling Address/f DIFFERENT 11 rom Fec/r/tyAddress Attention:or Care Of(opt/onal) <br /> 9499 North Fort Washington, Suite 103 Ken Sommers - <br /> MBIIIngAddreaeGty Fresno STATE zip <br /> CA 93730 \ <br /> BIC CODE APN# J�/ COMMEtf' ///���°°°������, <br /> THIRD PARTY BILLING INFO: Complete if Willing Party is different from Property Owner or FBClllty Operator ldenlYNed above. <br /> BUSINESS NAME Stantec Consulting, Corporation Attentlon;orCare Of (ODdonaq <br /> Ralph Carson <br /> Mal ing Address 3475 West Shaw Ave., Suite 104 PHONE (559)271-2650 <br /> CITY Fresno STATE ZIP <br /> CA 93711 <br /> ACCOUNTAOORE9a for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING Q <br /> BILLING COMPLIANCE At w ZMYIENT: 1,the ardersigeted Applicant,certify that I am the owner,Operator,or Aufi orked Agent of this Business,and 1 Rchnowledge that all Pe AuTFEes, <br /> Pev,V.nes,ENn)RCEMENTCNA Mand/or RODRLYC/ Ge associated with opention will be billed tome at the address ideuNBed abovea the ACCoCyyAonRess for this Site. 1 also certify that all <br /> information provided on this application u true and corrmp Sad that all regulated ac&ifcs will be performed in accordance with dl epph"ble SAN JOAQUIN COUNTY 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 facilitylsite address,i hereby authorize the release of <br /> any and aU results and environmental Aswament information to SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARTM n soon as it is rv.d.ble and at the some time it is <br /> Provided to me or my representative <br /> APPLICANT NAME(PLEASE PRINT) <br /> SI <br /> .��� Cj+IZS% DNATUR <br /> . <br /> _ �–_ —_ <br /> TITLE TAX IDM 33-L')36 .5-o 76 <br /> Approved BY Oab AoaountlnP O#iu Pro:aalnG Cmnpletad By �- Date <br /> SITE MITIGATION AMOUNT PAID DATE/OF PA ENT PAYMENT TYPE RECEIPT# CHECK Is RECEIVED BY <br /> FEE:E 3(�.rJC 43a.QJ 3/ Z�J O I �/ <. a"w! '.. ^ <br /> ansa �� <br />