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SANRQUIN COUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> DATE b /y/7 S� MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> 1 SITE MITIGATION & LOP <br /> SSHADEDAREAS FOREMDUSEOhM OWNER ID#01. OD2 /.-...0 QpgE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: ONECKWOMERIS CURR£NrLYONFMEANrN EHD El <br /> PROPERTY OWNER NAME <br /> FIRST Ml LAST PHONE NUMBER <br /> BUSINESS NAME Steven and Kimberly Kellogg Etal E�AII ADDRESS <br /> OWNER HOME ADDRESS 736 Mariposa Road #F <br /> CITY Modesto <br /> `AYE CA �" 95354 <br /> OWNER MAILING ADDRESS 736 Mariposa Road #F <br /> MAILING ADDRESS CITY Modesto STATE LP <br /> CA 95354 <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNETENr AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL AsSESSMENVI(—VOLUNTARY CLEANUP WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> FACILITY IDK IxvN AccouNr lD PR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB_DTSC_EPA_ <br /> FACILITY <br /> D0 aaar+z/4Y gs RO# s ,Lco� <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES No ! <br /> ISTHISAN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES No <br /> BUSINEs91FACILGY/SnWPR41)ECTNAME Kellogg Property <br /> SITE ADDRESS/PROJECT LOCATION 3808 West Lane SUITE# BUSINESS PHONE <br /> Cm Stockton STATE Ip <br /> CA 95204 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE Kul KEY$ <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF/OPTRMML) <br /> MAILING ADDRESS CITY STATE LP <br /> SIC CODE APN# I _ t73COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESSNAME Advanced GeoEnvironmental ATTERnOWORCARE OF (OPTMWAL) <br /> MAILING ADDRESS 837 Shaw Road PHONE 209-067-1006 <br /> CITY Stockton STATE CA LP <br /> 9szlS <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNERD FACILITY/BUSINESSE1 THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant certify that I am NIB Owner,Opervor,AuthorizedAgent,Or Repoosible Pao end I eelmooledw that All PERMIT fE&S, <br /> PENALTIES,RNPoRCEM£NTCRARGE.S and/or NDURLYCHARGES a45Mlated Nlth this project WIB be billed to meat the address ldendfied above IN,DM ACCOUNT'ADDaCss for this Site I also certify that all <br /> Information provided on this application Is true and Correct(and that all regulated activities Will be performed In accordance With all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL LAWS and REGULATIONS. As the undersigned Owner,Operator,AWROrizedAgem,orfrCtpoRFlbfc ParV for the profectlocated above underfacdlty/site acidness,I <br /> hereby authorize the release Of any and all results,repora,and other environmental asseSSsment information N SAN JOAQUIN COUNTY EYVIRONMENTAL DEPARTMENT as 90on 8S It is available <br /> and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) ILGY(�� SIGNATURE <br /> TITLE TAN IDK <br /> APPROVED BY '✓�`� DATE ACCOUMRNGOFTTCEPi EBMNGCOMPLEIEDBY DATE O I� <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECENED BY WORK PLANPE <br /> FEE:$ � <br />