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SAN Jr'AQUIN COUNTY ENVIRONMENTAL HEALTH nF:PARTMENT <br /> » GREEN FORM <br /> DATE Z� MATER FILE RECORD INFORMATION R <br /> if SITE MITIGATION &LOP <br /> W <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# N' 'V <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION. CHECK IF OWNER IS CURRENTLY ONF/LE w/TH EHD <br /> PROPERTY OWNER NAME ( ) <br /> FIRST Ml LAST PHONE NUMBER <br /> E-MAIL ADDRESS <br /> BUSINESS NAME <br /> Trustees of the California State University <br /> OWNER HOME ADDRESS <br /> CITY STATE ZIP <br /> OWNER MAILING ADDRESS <br /> 401 Golden Shore <br /> MAILING ADDRESS CITY Long Beach S�pIE Z'P 90802-4210 <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ®RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP X <br /> FACILITY ID# INV# ACCOUNT ID PR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD�_RWQCB_DTSC_EPA <br /> ul�°a� <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION—: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO [}� <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES EI No ❑ <br /> BUSINESS/FACILITYISITE/PROJECT NAME Former Stockton Developmental Center <br /> SITE ADDRESS/PROJECT LOCATION 1252 Stanislaus St. (also known as 702 N. Aurora St.) SUITE# BUSINESS PHONE <br /> CITY Stockton STATE CA zip CA <br /> BOARD OF SUPERVISOR DISTRICT v I LOCATION CODE ,y I KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS V ATTENTION:ORCARE OF(OPTIONAL) <br /> 401 Golden Shore Steven Lohr <br /> MAILING ADDRESS CITY Long Beach CATS Z'P 90802-4210 <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ATTENTION:ORCARE OF (OPTIONAL) <br /> Condor Earth Technologies, Inc. <br /> MAILING ADDRESS PHONE <br /> PO Box 3905 (209) 532-0361 <br /> c'rySonora sCAAE zIP95370-3905 <br /> =AccoUNTADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING® <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: [,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent,or Responsible Party and I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFoRCEMENTCl/AROES and/or HOURLYCFL4RGES associated with this project will be billed tome at the address identified above as the ACCoUNTADDRESs for this site. I also certify that all <br /> information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operator,Authorized Agent,or Responsible Party for the project located above under facility/site address,I <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRO NMNTAL HEALTH DEPARTN NT a5 oon as it is available <br /> and at the same time it is provided to me or my representative. /) <br /> APPLICANT NAME(PLEASE PRINT) 1 SIGNATURE , <br /> JZ <br /> TITLE L <br /> TAX 2-7 dO Sd <br /> APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY d DATE <br /> SITE MITIGA ION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY '� WORK PLAN PE <br /> FEE:$ �"Z <br />