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9 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATEof/zn/gals MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED ARESS FOR END USE_ONLY OWNER IDN CASEY UNIT IV <br /> OWNER FILE:COMPLETE PROPERTYOWNERI RESPONSIBLE PARTY INFORMATION: CHMKFOWERts CuRRENrcromriLewnNEHDLI <br /> PROPERTY OWNER NAME Steve Kellogg <br /> FIRST MI I LAST PHONE NUMBER <br /> BUSINESS NAME Steven and Kimberly Kellogg Etal EiMILADDREeS <br /> OHNERHOMEADDRESS 736 Mariposa Road #F <br /> CRY Modesto <br /> SPATE CA nP 95354 <br /> OWNER MAILING ADDRESS 736 Mariposa Road #F <br /> MAILING ADDRESS CITY Modesto STATE LP <br /> CA 95354 <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> FAcarnlD# INVN AccouNT ID PRWRON ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB_DTSC_EPA_ <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: ,vt <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY TH E ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No la <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES)CI No ❑ <br /> BUSINESSIFACILm'ISITEIPROJECTNAME Kellogg Property <br /> SITE ADDRESS I PROJECT LOCATION 3808 West Lane SUITE Y BUSINESS PHONE <br /> CITY Stockton STATE CAPP 95204 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIOHAL) <br /> MAILING ADDRESS CITY STATE LP <br /> SIC CODE APN Y ; t7- <br /> _ O Z�^ -01! <br /> .Q I COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE, <br /> BUSINESSNAME Advanced GeoEnvironmental ATTENTION:ORCARE OF(OPrrO ) <br /> MAILINGADDRESS 837 Shaw Road PHONE 209-467-1006 <br /> CITY Stockton STATE CA LP <br /> 95816 <br /> AOCOUNT ADDRESS TO SEND FEESAND GRANGES: OWNEREI FACILRY/BUSINESSQ THIRD PARTY BIWNGDQ <br /> BILLING AND COMELIANCE ACKNOWLEDGMENT: L the undersigned Applicant,certify that I am the Omer,Operator,AuthorizedAgeut,or Responsible Parry and I acknowledge that all PERMIT FEES, <br /> PENALTI£s,Eotzxnc sew CHARGES and/or HOURLY CHARGES associated With this proje ti WIII be hulled to meat the addrt9S Identified above as the Accou TADDR£SS for this Site I alsocertlly that aN <br /> information provided On HIS application is true and Correct,and that all regulated aetiNties Will be performed in accordance With all applitable SAN JOAQUIN COUNTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL Laws a ad REGULATIONS. AS the mlderdiped Oantr,Opuatar,AunhorizedAgent,or, Responsible Party'for the Project located above Under facility/site addree,I <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENnaONalTi! AL IfEALTH DEPARTMENT US Soon es It IS available <br /> and at the same time it is provided to me or my representative <br /> APPLICANT NAME(PLEASE PRINT) Daniel villa..... SIGNATURE <br /> TITLE Kellogg Property Tar IDP <br /> LA C <br /> PPROVED BY BATE ACCOUNDNG OFFlCE PROCESSING COMPIIREDBY PATE <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECKY RECEIVED BY WORK P4IN PE <br /> FEE: <br />