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San Juin County Environmental Health Oartment <br /> DATE11 3/16/12 MASTER FILE RECORD INFORMATION "MFR1e /('H'T GREEN FORM <br /> /IL...--rrr SITE MITIGATION & LOP <br /> 71 <br /> SHADEDARFASFOREHDUSEONLV OWNERID# / )0^/ if -7 CASE# 50oo("`p? UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOWiNG PROPERTY OWNER lwoRMA7xw. CNae OWNER CURRENTLyONFILEW EHD � <br /> PRove rYOWNERNAME Elizabeth =P <br /> erry ( ) 415-868-1139 <br /> Fiat MI Last PHONENUMBER <br /> BUSINMIR ME Vacant EHaAILADDRESS <br /> OWner Home Address 7480 Panoramic Highway <br /> city Stinson Beach 'CA Z'P 94970 <br /> Owner Melling Address P.C. BOX 1131 <br /> Mailing Add—CRY Stinson Beach se Zip <br /> Zip 94970 <br /> CORPORATION❑ INUIVIOUALN PARTNERSHIP❑ FEOAGENCY❑ OTHER❑ <br /> Sine MIn"nobi_ENVIRONMENTAL ASSMSMENT k VOLUNTARY CLIANOP WAT!R QUALRy—HW Pipauh s INVEsneATON_LOP <br /> FAcIUTYID# Inv# Account lD PR# O# ASSIGNED EMPLOYEE LEAD AGENCY:EHD�RWQCB_DTSC_EPA_ <br /> 8Y 02 /cr99 <br /> FACILITY FILE COMPLETE 7HEFOLLOw(NG BUSINESS if FACILITY If SITE INFORMAnom, <br /> Is this a New Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ® No ❑ <br /> Is this an EKISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESSMACILRYISITENAME Vacant - Formerly Hollywood Video <br /> Sm AOURESS 678 North Wilson Way sun-E# BUSINESS PHONE <br /> Cm Stockton STATE ZIP CA 95205 <br /> SOARDOFSUPERWSORDISIRICT LOCATION CODE I KE11 KEYZ <br /> Mailing Address ND/FFERENr#mn FacWAddress Attention:orCare Of(opblanato <br /> Meiling Address City STATE ZIP <br /> SIC CODE APN# COMMENr: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESSNAME AEI Consultants, ATTN: Bryan Campbell Attention:or-Care Of(op#mMft <br /> Melling Address 2500 Camino Diablo PHONE (925) 746-6044 <br /> CITY Walnut Creek, CA 94597 STATE zip <br /> 6ccoui26OOHES.T for fees and chargee OWNER FACILITYIBUSINESS HIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: L the undersigned Appliun4 cerfih that i am the(Mader,Operator,or Authorized Ages of this Business,and 1 acknowledge that all PER.UIT£E£S, <br /> PENALTIES,EmmitcEMENT CHARGES and/or HOt/RLY CHAR(;EP associated with this operation will be billed to me at the address identified above as the Ac'couATADDREY.0 for this site. 1 also certify that <br /> ail information provided on this application is true and correct and that all regulated activities will be performed in accordance with all applicable SAN JOAQUH COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or IEDERaL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facilkylsite address,i hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR'rN a n as t is mailab rid at the same time it is <br /> provided to me or my represenbfi"e. Bryan Campbell, AEI Consultants <br /> APPLICANT NAME(PLEASE PRINT) SIGNATURE / <br /> TITLE Program Manager TAX ID# 680288965 1l 1�I <br /> Approved By I Data Aceeunting Office P oceaabg Completed By Dab <br /> SITEMITIGATION AMOUNTPAID DAT�E0 PAYMENT PAYMENT TYPE RECEIPT# CHECK#�/ RECEIVED BY WORKQPLLaNNPE <br /> FEE:111 Jr) 3?� <br />