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San Jo. ,uin County Environmental Health D� _artment <br /> DATE MASTER FILE RECORD INFORMATION MFR" GREENFORM <br /> SITE MITIGATION&LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CABS1# UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOWING PROPERTY OWNER INFORMATION. CNECKIP OWNER C!FRRENTxYON FILE wrN EHD <br /> PROPERTY OWNER NAME Daniel Folcher (856)470-2727 <br /> First MI Last PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> Four B's Partnership Dan.Folcher NFllndustries.com <br /> Owner Harte Address <br /> City STATE LP <br /> Owner Mailing Address <br /> 71 W. Park Avenue <br /> N II ne and c� NJ State Zip <br /> 08360 <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP IA FEDAGENcY❑ OTHER❑ <br /> SIT!MmoATHm_ENVIRONMENTAL A88E$SIIImw_VOLUNTARY CLEANUP_WAhmn QUALny T HW PiPieJNE INVI• "TION____LOP <br /> FACILITY ID# INVA I ACCOUNTID PR A CRO Assmen EMPLOYEE LEAD AGENCY:EHD_RWQCB_DTSC_EPA_ <br /> FACILITY FILE COMPLETETHEFOLLOW/NG BUSINESS I FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEAL DEPARTMENT? YES ❑ No <br /> Is this an FASTING Business LOCATION buta NEW TYPE of regulated Business? YES ❑ No 91 <br /> Bus'NESSIFAciuTYfSITE NAME <br /> Ni <br /> SrrEAi3oFwm SURE# BUSINESS PHONE <br /> 2850 Loomis Road <br /> Stockton CA z�P 95205 <br /> BOARD OF SUPERVISOR DISTRICT LacAmm Cooe KW KEY2 <br /> Mall Ing Address 1fD1PMWNrJrxlm FacNIyAddresa Attention:orCare Of(opfinual) <br /> 71 W. Park Avenue Mr. Daniel Folcher <br /> Mailing Address City STATE ZIP <br /> Vineland NJ 08360 <br /> SICCODE APN A 7 9 -/,0 o - 4 311 11 <br /> COMMENT <br /> THIRD PARTY BILLING IINFO: Complete if Billing Party is different from Property Owner orFacility Operator idenbried above. <br /> BUSINESS NAME AtUntion:orOare Of(Cpflona1J <br /> Advanced GeoEnvironmental, Inc. <br /> Malling Address PHONE <br /> 837 Shaw Road 209 467-1006 <br /> Cr" STATE ZIP <br /> Stockton CA 95215 <br /> AamacmTAamm for fees and Charges OWNER FACluTYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPI,tANCF,ACKNOWLEDGMENT: 1,the undersigned Applicant certify that 1 am the!honer,( erator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENTCHAROES and/or HOURI.YCHARaE.V associated with this operation will be billed tome at the address identified above as the ACCOUNTAI)I)RE s 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 perfoimed in accordance with nil applicable SAN JOAQUIN COUNTY Ordinance Codes andlor . <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent o�the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANTNAME(PLEASE PRINT) Robert E. Marty SIGNATURE <br /> Tax ID# <br /> TITLEPresident ^► <br /> Approved ay Dote Acanunting Office Processing Cam leted By ate <br /> SITE MITIGATION I AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE:$ 5021 <br />