Laserfiche WebLink
'Jun. 4. 7013 3:37P TDWICON <br /> i No, 1305 P. 4 <br /> San Juin County Environmental Health DE'jtrnent <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> SITE MITIGATION&LOP <br /> 9NA Us s , UNIT IV <br /> _SED AREAa PON�_tlD <br /> USE ONLY VWN <br /> ER'ID# � <br /> OWNER FILE:CammETFPROPERlY OWNER/RESPONSIBLE PARTY/NFORm 770N.' CHFcxrF OWNER aunRFatrzvavr"wm+END ❑ <br /> PRopVmQwNimNAME City of Tracy (204831-6460 <br /> First MJ Lest PHONe NUMBEK <br /> i <br /> e.rwILADDaFss � <br /> SUBMEN NAME <br /> Dwrw•f Nome Addram; <br /> Off' Tracy SrAT9 CA Lr 95376 <br /> OsmarMallltwgAdd-- 333 Civic Center Plaza,Tracy <br /> "aAddr*06Ofty 333 Civic Center Plaza,Tracy statOCA aP 95376 <br /> ❑CORPORATION ❑INDlYMUAL ❑PARTNERSHIP ©GOYERNIaEw AGENOY ❑RvsPONSIBLE PARTY ❑ch"m <br /> Srm IArnGATIOr1_ENVIRONMENTAL ASSESSMENT,VOLUNTARY CLEANUP_WATER QUALITY_MW PIPEUNE INVESTIGATION LOP <br /> FAcltm IDP INwa Aocounr ID PR A!R A AserY�N;€o EMPIAYEE ruti'o Ai£ENair:END":,`R4YQC6'-=pTt3C EPA's:: <br /> FACIL11rY FILE: CDINPLm BUSINESS ISITEI PROJECT INFCRNATION: <br /> Is this a NEW Project LocATtON not praviou'sly regviatod by the ENviRONMEWAL HEALTh DEPARTMENT? YES ® No ❑ <br /> Is this an EXISTING Project LOCATION but a NEW SCOPE OF WORK? Yes El NO ❑ <br /> BUDne5mXAnnrr nwEft6AOTNAME Boyd Service Center <br /> SUTMO BUSW AIN PHONE <br /> SrmADaREBErPRod>:cTLdOAMON 560 Tracy Boulevard <br /> SATE "95376 i <br /> crrY Tracy CA <br /> LgcATterN CGDE KE" KE+2 <br /> BoARo�$NpERYrROR pi$TRtcY � � � ' <br /> Mallbrp Adcinw*KOIFrrmeNr*am FadlKyAddrtm— Atterwtion:orCary Or( aarNwlj <br /> STATE ZIP <br /> mouhwr)Address CRY <br /> SIC CODE APH 0 fi4Mr�ENt <br /> THIRD PARTY 13ILLING INFO: COT lett=if EMIlling Party is diffierent from Property Owner orR Ible Party identified above, <br /> 13tJ81HEes NAatE Attealloru orCare Of (00—aU <br /> Technicon Engineering Services, Inc. <br /> 1 <br /> Mlaulrt mdresa 45391 .Brawley Avenue,Suite 108 PHONE 559-276-9371 <br /> STATE CA zip 93722 <br /> Fresno <br /> for few and chargee OWNER FAGIL[TYl�USiNESS <br /> THIRD PARTY BILLING <br /> Wag@gW <br /> Rrr t3Nr AND COhIDL6tNCB ACIOCOWL5P�79ELI 1,the unders*ad Appfiraay certify that 1 Am the O%acr,0peruiory AwkuriZtdAyex;or1lapo7Lnbtc lfru¢'and I aclm�.a [c.dP�aalso drat <br /> Gu utCEs andlOr HOaxiYCtrnRCks essocialed witb this Project wW be billed to mt of the address identified above as the At eoukY J r this Ord'eao leo Coda and/or <br /> tala <br /> ETFORC7EMErT - al a usable SAN JOAQtDN <br /> infgn 2tio wM be rformed iD pecordantt uTdl k PP <br /> inrorplation provided an Ik,jy appliukon IS tree and corroc4 And that all repumfed activi4eT EK <br /> Smndarda asd STATE tadfor FEpyRAl.I,"And Regulations As the wdenivicd owner,operato<,Authorized Agway or Respomilk Party for the project located above under fACWtti'loite rddress I <br />' Lcreby authar>R she release of any Grad all results,reptxa and other e1+.vvnmtDOl asseasmatl information to SAN JOAQUIIV COt1NTY&W1RONMES TAI.AEALTH DI;FARTMENT as soon at;it i <br /> is available and at tba ssrM time it it prmided touo or my►<Premtativ 4 <br /> APPLICAKTNAME(PLEMEppwT) Darren G.Williams SI4HATupa <br /> TAx ID A 77 209487 <br /> T1TIS President/CE-0 <br /> AcaetawTlny Office,PYacawl++6 Wtod Date <br /> Dole .... <br /> gtrnMmoAbm AMOVNTPAIO <br /> DATE OPPAYaIaNr <br /> PAYMENT TYPE RECEIPTS CHEDKd KEcm PD-BY •'WORx��-44J'P.E".;;`„' <br /> FEE.$ <br />