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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> �E >•>' GREEN FORM <br /> DATEP.AREASF.R <br /> ZS MASTER FILE RECORD INFORMATION MFR SITE MITIGATION & LOP <br /> GA9E# n , UNIT IV <br /> 5 ADFHD EONLY OWNER ID# Sa �� <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: <br /> CHECKIFOWNERW CURRENTLYONFILEWITH EHD <br /> PROPERTY OWNER NAME <br /> FIRST MI LAST PHONE NUMBER <br /> E-MAIL ADDRESS <br /> BUSINESS NAME Trustees of the California State University <br /> OWNER HOME ADDRESS <br /> STATE ZIP <br /> Cm <br /> OWNER MAILING ADDRESS 401 Golden Shore <br /> $IptE LP 90802-4210 <br /> MAILING ADORESSCT' Long Beach (l�.fA� <br /> [1 CORPORATION ❑INDIVIDUAL El PARTNERSHIP ❑GOVERNMENT AGENCY ©RESPONSIBLE PARTY <br /> OTHER <br /> SITE MITIGATION <br /> ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP X <br /> FACIUTYID# It ACCOUNT ID PR#IRCI# ASSIGNED EMPLOYEE LEAD AGENCY:EHDJ6_RWQCB_DTSC_EPA_ <br /> pp�bzA -- <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> YES ® No ElIS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? <br /> BUSINESSIFACILITYISITOPROJECT NAME Former Stockton Developmental Center <br /> w� <br /> C SURE# BUSINESS PHONE <br /> SITE ADDRESS I PROJECT LOCATION 1252 Stanlslaus St. (also known as 702 N. Aurora St.) <br /> J RCA LP95202 <br /> GIT! Stockton <br /> ��Y K 71 KEY2 <br /> BOARD OF SUPERVISOR DISTRICT V I LOCATION CODE �) <br /> ATTENTION:ORCARE OF(OPTIONAL) <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS Steven Lohr <br /> 401 Golden Shore <br /> STATE LP <br /> MAILING ADDRESS CRY Long Beach CA 90802-4210 <br /> SIC CODE APN# COMMENT: <br /> i 1 o-off <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER R RE PONSI LE PARTY <br /> IDENTIFIED ABOVE. <br /> ATTENTION: <br /> RCARE <br /> BU91NESs NAME Condor Earth Technologies,Inc. <br /> PHONE <br /> MAILING ADDRESS PO Box 3905 (209) 532-0361 <br /> CITY Sonora BET zip <br /> p95370-3905 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: <br /> OWNER❑ FACILITYIBUSINESS❑ THIRD PARTY BILLING® <br /> BILLING AND COMP IA ACKNOWLEDGMENT' 1,the undersigned Applicant,certify that 1 am the Owner,Operator,Authorized Agent,or Responsible Party and 1 acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORC£MEAT CHARGES ana/or HOURLY CHARGES associated with this project will be billed to me at the address identified above as the ACCOUNTAmRE55 for this site. I also certify that all <br /> information provided on this application is true and correct; and that all regulated acfivifies will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or <br /> nt,or <br /> nsible Party <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS.and other environmental undersigned <br /> asOseFsmeN�nformation to SAN JOerwar,Authorized eAQUIN Ce00NTY ENYIR f MENTAL Hor the EALTH UEPARTt[mated VMENTT M e under f moot resit isaavai able <br /> hereby authorize the release of any and all results,reports, <br /> and at the same time it is provided to me or my Tepresemative. v <br /> N �� j "G SIGNATURE <br /> APPLICANT NAME(PLEASE PRINT) ` <br /> ,T ] I - <br /> J /J �'^ TAX ID# cls �sO�jQ <br /> TITLE �Ii/si GD/� C ^I(zL I�I� � <br /> APPROVEDBY GATE ACCOUNTING OWIGE PROCESSING COMPLETED BY <br /> DATE <br /> RIPT# CHECK# RECEIVED BY WORN PIAN PE <br /> SITE MITIGA ION AMOUNT PAID ATE OF PAYMENT PAYMENT TYPE ECE <br /> FEE: / 1111 ,r n/ <br />