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San Juin County Environmental Health I.nrtment GREENFORM <br /> DATE MASTER FILE RECORD INFORMATION MFR SITE MITIGATION &LOP <br /> (L( UNIT IV <br /> SHADED•- D Ii O O EHY OWNER ID# CAGES O � 1 JD('p <br /> CHECK,OWNER CURREATLYONnLE nam EHD <br /> OWNER FILE:CoIxvLErETHEFMLowrNaPROPERTYOWNER/NFORMaTroN' X09) 524-2230 <br /> PROPERTY` Mabel Keir <br /> OWNER NAME PHDNENUIIBER <br /> First MI Last <br /> r-MAILAD0flF88 <br /> BUBNESS NAME NA <br /> Diner Hone Address 1103 Grantland Court <br /> STATE LP <br /> cry CA 95350 <br /> Modesto <br /> Owner Milling Adder as above <br /> Side ZIP <br /> Mailing Address CRY <br /> COflPORATION❑ INDIVIDUAL® PARR1EflaHIP❑ <br /> PED AGENCY❑ OTHER C3 <br /> SRL Nimaje ION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER CUALFTY_HW PIPELINE IN IES IGATION,_LOP-_ <br /> FACILITY ID# INV# ACCOUNT ID PR RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RW4C8._DT$C_EPA_ <br /> Q13?2.2 /SLS l S9 <br /> FACILITY FILE COMPLETE THEFOLLOW/NO BUSINESS I FACILITY I SITE INFORMA770W <br /> Is this a NEW Business LOCATION not Previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes El No <br /> yes [I NO <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? <br /> BIIBINESSIFACILITYISRENANE Lopez Property <br /> SURE# BIINNESSPIpNE <br /> SITE AODREbe 1601 Turnpike Road <br /> SPATE LP <br /> L.mY, CA 95206 <br /> Stockton <br /> BOARD OF$UPERVIEOfl DISTflICT LOCATON CDDE <br /> KErt KEY2 <br /> Attention:O Care Of(OPhiond) <br /> Me 111 ng Address dDIFFERENT#oN FAoMyAd~ Mabel Keir <br /> 1103 Grantland Court <br /> STATE 7JP <br /> Mailing Address City CA 95380 <br /> Modesto <br /> SIC CODECDMNFxr: <br /> �N#lGS-0 � 0 - !3 <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFacilily Operator identified above. <br /> Atfenlbn:o GC 01 (OPEOWRobert Marty <br /> BUaINE-NAME Advanced GeoEnvironmental Inc. <br /> PHONE <br /> Meiling Address 1-209-467-1006 <br /> 837 Shaw Road STATE LP <br /> Cm CA 95215 <br /> Stockton <br /> AOQQ(#12ADDWB forfeq and chargee <br /> OWNER FAciuTYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE AC"OWLEOGMENI': 1,the undersigned Applicant,certify that 1 am the owner,Operator,or Authorized Agent of this Business,end I acknowledge that all PERMYT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as thea SAN J AQUIN COUNTY for this site. I alrdianne,so des aY Char <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable NAN JOAQUIN e er boauthoriu the release of <br /> Standards end STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of 1M1e properly located at the above facility/vice address, Y <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART 'NT M a on m t ' available and at the same time it is <br /> provided to me or my representative. <br /> Robert Mart SIGNATURE <br /> APPLICANT NAIAE(PLEASE PRINT) Y <br /> TAX <br /> TAX ID# NA <br /> TITLE President <br /> Approved By Dab <br /> Accounting Office Processing Com lama By Dale le, 2— <br /> SPLAIN <br /> ITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY W3RSO IE <br /> FEE: <br />