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San Juin County Environmental Health aartmCent <br /> DATE11 3/16/12 MASTER FILE RECORD INFORMATION "MFR" ) IL-E GREENFORM <br /> SITE MITIGATION & LOP <br /> SHADEDAREAS FDR EHO USE ONLY OMER ID# CASE 15&0( g507 UNIT IV <br /> OWNER FILE:COMPLETETNEFOLLOW(NO PROPERTY OWNER lwoifi iinom CWBC#IFOWNER CumrexrLrox miimEHD❑ <br /> PROPERTY OWNER NAME Elizabeth Perry ( ) 415-868-1139 <br /> First MI Last PHONENUMsea <br /> BUSINESS NAME Vacant E R.ADDItm <br /> O`NnM`H01D°Add1°" 7480 Panoramic Highway <br /> Dfty Stinson Beach BTATECA LP 94970 <br /> OWnsr MalGg Address P.O. BOX 1131 <br /> IAaMng Ad 1ORy Stinson Beach Stab zip <br /> ry5 CA 94970 <br /> CORPORATION[I INDIVIDUAL I`_y PARTNERSHIP El FED AGENCY E] OTHER El <br /> SITE MITIGATWN_ENVIRONMENTAL AffIfaMIX►X VOLUNTARY CLEANUP_WATER QUALEY_HW PIPELINE INVESTIGATION_LOP_ <br /> FACILITYID# INV# ACCOUNTID P ROP ASSIGNEDEMPLOYEE LEAD AGENCY:EHD-X—RWQCB_DTSC_EPA_ <br /> q3 /&99 <br /> FACILITYFILE COMPLE7F7HEFOLLOW/NGBUSINESS/FACILITY/SITE/NFORMARoN• <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ® No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No [21 <br /> BUSINESSIFACILRYISRENAME Vacant - Formerly Hollywood Video <br /> SREAODRESS 678 North Wilson Way SURE# BUSINESSPHONE <br /> CITY Stockton STATE ZIP CA 95205 <br /> BOARGOFSUPERVISORDISTRICT LOCATION Dom REYI KEY2 <br /> Mailing Address;KO/FFERENThan FacRWAddiesa Attention:orCare Of(optlda/J <br /> Mailing Address City STATE ZIP <br /> SIC CODE <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:orCera Of(opaantop <br /> Melling Address 2500 Camino Diablo PHGME (925) 746-6044 <br /> CITY Walnut Creek, CA 94597 STATE ZIP <br /> AGm(PoQAmnsal,forfees and Charges OWNER FACILITY/BUSINESSHIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACNPOWLEDGNIENT: I,the undersigned Applicant,certify that 1 am the Owner,Operstor,or Authorized Agent of this Business,and 1 acknowledge that all PERHIT FEES, <br /> PENALTIES,ENFORCEMEATOY R ES and/or HOURLY CNnxo'ES associated with this operation will be billed to me at the address identified above as the ACCDUNTAnORess for this sim l also certify that <br /> at,information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIR COUSTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby auNorae the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART A a 1 as t is availab nd at the same time it is <br /> provided to me or my repreaentatiec Bryan Campbell, AEI Consultants <br /> APPLICANT NAME(PLEASE PRINT) SIGNATURE j <br /> TITLE Program Manager TAXID# 680288965 <br /> ApproSed By Dab Accounting O I..Proceming Completed By Deb <br /> SITE MIT'IIGAATION � ANGLN2LT PAID DATE OFPAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVEDBY WORN PIAN PE <br /> FEE:S J.TJ J�J 3 -/y-,Z �U 31'15 QTI� ��SU <br />