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_ San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHApFP1gEARFQAENOMEDray OWNER ICE CARE{ 7047 UNIT IV <br /> OWNER FILE:COMPLETEPROPERTYOWNER/RESPONSIBLE PARTY/AmMmArAol CNIFOYaONERCURUENnroA,FArNmrEND0 <br /> IFPxnER,YowNE"NAFE Steward Sobek (415) 617-5791 .J <br /> First NI USI NIor1E NuesER <br /> Busam ss NAME Stuart Limited Partnership ErA1LAooREse <br /> OWlrer Norse Addreq <br /> CIN STATE 2r <br /> OVA1wMailing Address P.O. Box 370055 -- <br /> Mailing Address City Las Vegas Stats NV Z4 <br /> 89137 <br /> ❑CORPORATION ❑ImotocuAL ®PARTNERSHIP ❑nowsusamr Amicar ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION _ ENVIRONMENTAL Assesssrl VOLUNTARY CLEANUP_WATER QUALITY___NW PIPELINE INVESTIGATION_LOP <br /> FAcnl,r loR INve AocoUlrt lD PR BIROS AseIaRED EJPto ME LEAD ADENOY:ENO�C_RWQCB_DTSO_EPA_ <br /> FACILITYFILE: COMPLETEBUSINESS/SITEI PROJECT/NFORMATION: <br /> Iat11152NEW Protect LOCATK/NlK/t preVloltlly regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES NO ❑ <br /> Is this an EXISTING Project LOCAs NI but a NEW SCOPE OF WORK? YET ❑ Na <br /> BUSaaERS FACT RYl&E PPO ECTNANE Quality Cleaners,Tracy Corners Shopping Center <br /> I <br /> SREAOORESSIPOWECTLOCATbN SUITES BUSINESS PHONE <br /> 3081 North Tracy Boulevard <br /> Cm <br /> Tracy STATE ZIP <br /> !] CA 95376 <br /> BOARD of SUPERVBao OMTR LOCATiom COOS NEW KEY2 <br /> Mailing Addmas NDIFFERENT#oo,Fa AyAobTssa `•1 Attention:wCRn Of/opbonsf/ <br /> Mailup Address City STATE ]JP <br /> SIC ewe APN a COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Responsible Party identfiedabove. <br /> BUSINESS NAME Partner Engineering and Science, Inc. At"w""`°FG"re of (Op&vwS Tom Campbell <br /> Halling Address 2154 Torrance Boulevard, Suite 200 PHomE 508-876-2660 <br /> Cnv <br /> Torrance STATEryA zM 90501 <br /> AC.P9_N for fees and charges OWNER FACILITYIBUSINESS 1. THIRD PARTY BILLING <br /> BILLING.%%1)(70a1111 A\(f At k,U.I I M'NF\T: 1,des Medrrfirrc \,Plica.,Mrlih fhnl I am IM/AnNr.IIFY"Wrr.:I.Ik—km TEfW.`RelpnniNe PurnaM 1 ML I d t6l aB PRA Irn Irl c <br /> P[.N:U nn,EIMAI F-Afr"('IURCES AMrm IIUI'AtI 1 11 4AIX1 a,IKul,d nilh dais Prajcrl nAt 1.hdL f m me as the NAdro,miTudGM aM,,na dM AI,,,,I'IhOALY)rw IN,,iln 1.hu emjf,Ih.Y.11 <br /> infnrnMdnn pnnikJ an Ih6 APPlkniaa A irur.M aNreer, end 1h.,.11 T,p ,M acd,hw,niN IN pedlx IaNA in• mdvmr nils vY NIPik-l'k G\h Ju,(g1 IY(OLVII Ordinance('ndYa unpnr <br /> .Fandalds arMl 5T\n:vmlhm Erhranl Ianf aM HrEM1.H1Mn l<IM IIIldfniEawd I IaVMI,(11NYMIM.lnlMnirell \EMICOY NPiINNe1M!PurIM1 fnr des prnjrn krmnl MMTr IuMrr(aiin;.iM nAdm,.1 <br /> herrhr.ulhnrRP IIMrek.o ofRm aM.R rnWO,rggrb,aYW IdlnrmvirnmlYnl.I Maae.mrn(inlwnudun IM`.\ .111.\I)1IN(OrNil LN\IRII\NFYMI.FIF.\I 111 nFPARI\IE\I aa.,vm:nn <br /> u vavilahlc ud al Ihr unn Iinx'n i.PnnidM to nm or m,rcPrsenlaliYr. <br /> APPLICANT NAME(PLEASE PRWT) Tom Campbell SIGNATURE <br /> TITLE Project %lanagei TAxID N� <br /> SITE MII ICATION AMOUNT PAm DATE Of PATMENT PAYMENT TYPE RFCEIP a <br /> r7Cr r{ CHECNa RtcE YFo Y <br /> WORK PLAN PE <br /> Fee:L <br />