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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH APARTMENT <br /> DATEMASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> OT/23/2015 <br /> SITE MITIGATION& LOP <br /> SHMED FOR END USE ON OWNER IDX CASE UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER Is CURRENTLY OW FILE WITH ENDO <br /> PROPERTY OWNER NAME Steve Kellogg <br /> FIRST MI LAST PHONE NUMBER <br /> BUSINESS NAME Steven and Kimberly Kellogg Etal E-MAIL ADDRESS <br /> OWNER HOME ADORE" 736 Mariposa Road #F <br /> CITY Modesto <br /> STATE CA LP 95354 <br /> OWNER MAILING ADDRESS 736 Mariposa Road #F <br /> MAILING ADDRESS CITY Modesto STATE z" <br /> CA 95354 <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENTAGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP WATER QUALITY HW PIPELINE INVESTIGATION LOP <br /> FACILITY IDX INV# ACCOUNT ID PR#IROp 'A69IGNE0 EMPLOYEE LEAD AGENCY:EHD_RWQCB_DTSC_EPA_ <br /> �i4a�2zgSJ f�.eno4Zi`� 2Ds`folYS <br /> FACILITY FILE:COMPLETE BUSINESS/SITEI PROJECT INFORMATION: ,M�.t <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YEs El No No <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES X] NO ❑ <br /> BUSINESSIFACILITYISITEIPROJECT NAME Kellogg Property <br /> SITE ADDRESS I PROJECT LOCATION 3808 West Lane SUITE BUSINESS PHONE <br /> c- Stockton STATE CALP 95204 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(CIPDOWAL) <br /> MAILING ADDRESS CITY STATE LP <br /> SIC CODE APN# '1 l_ O 3 d — rrl I COMMENT: <br /> IL- I <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME Advanced GeoEnvironmental ATTENTION:ORCARE OF (OPTIONAL) <br /> MAILINGADDRESS 837 Shaw Road PHONE 209467-1006 <br /> CITY Stockton STATE CA LP <br /> 95816 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNEREI FACILITY/BUSINESSQ THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undemigned Applicant.Certify that I am the(bane,,Operata,ARtlariz dAgent,oT ResSmsihle Part;and I acknowledge that all PFRMIT FEES', <br /> PEAlUTIE.I',CNFOR('E.NENT CHARfiLP and/or HOURLY CHARGE.T a55celated With This project Will be billed tome at the address Identified above aS the AI.I 01,N7 ADDRE.S1'for this Site 1 also certify that all <br /> information provided on this application is true and correct;and that all regulated activities WIB be performed in accordance With all applicable SAN JOAQUIN COUNTY ORDINAN(F.CODES and/or <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATION'S. AS the undersigned!Avner,Operator,Auth S-ked Agent,or Responsible Parti,for the project located above under facility/site address,l <br /> hereby authorin the release Of am,and all results,reports,and other environmental assessment information M SAN JOAQUIN COUNTY ENVIRONS AL HEALTH DEPARTMENT aS Soon aS it is available <br /> and at the Same time it is provided to me or my representative <br /> APPLICANT NAME(PLEASE PRINT) Daniel Villanueva SIGNATURE <br /> Z` <br /> TITLE Kellogg Properly TAX ID# - <br /> APPROVED BY DATE ACCGUNrND OFFICE lancosmaw COMPOSTED BY DATE <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECN# RECEIVED BY WORK PUN n.PE <br /> FEE:$ .2-7J V <br />