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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT GR Rohl G I N A L <br /> "� MASTER 04/11/201a FILE RECORD INFORMATION"MFR" <br /> SITE MITIGATION&LOP <br /> $HASEDIREAE COR�HP_U,E.DN`S Owham IDM CAEEB UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CN wONNERATCMRe nrwVPRE EHD❑ <br /> PRDPEKTr OwxDa NATE Victor Aranda 209) 464-8675 <br /> FLPST AE LIST PHDNE NwSER <br /> BUMNE88 NAME EA1,11LADOPfSs <br /> N/A N/A <br /> OWNER HOME ADDREaE <br /> 5487 East Marsh Street <br /> Cm BTATc Zr <br /> Stockton CA 95215 <br /> O'ER MARUNIOA Ff1 1318 East Scotts Avenue <br /> MAUMO ADalmes Cm <br /> Stockton B'"n n' <br /> CA 95205 <br /> ❑CORPgUKTKiN ❑INDIVIDUAL ❑PARTNERSHIP C GOVERNMEMr AOENOY 0REaPOu81BlE PM1Y ❑QTNER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY HW PIPELINE INVESTIGATION LOP X <br /> FACILITY IDE INVk ACCOUNi1D PREIROW ASSIGNED EMPLorEE LEAD AGENCY:EHD_RWQCB_DTSC_EPA_ <br /> FACILITY FILE:COMPLETE BUSINESS(SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YEs ® NO ❑ <br /> BUSwEBSIFAClI iSITEIPRQI N <br /> Former Ocam o Property <br /> SITE ADDRESS I PMCCT Locant MI SUYEX BUSRIEsephaam <br /> 821 South Wilson Way <br /> CITY Stockton CA' aP <br /> 95205 <br /> BOARD OF$UPERVI&OR DISTRICT LOCATION CCOE KfYI KEY2 <br /> MAILING AD ehi IF DIFFERFKT FROM FAcam ADDRESS ATrEN1dON:ORCAREOE/OPIKWAL) <br /> 1318 Scotts Avenue Victor Aranda <br /> "LING Awkints CITY STATE ZIP <br /> Stockton CA 95205 <br /> SIC CODE APNY CDMMENr: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> Butimess NAME ATTENTION:cnohR OF(CPNDVAL) <br /> MAR-me ADDRESS PHONE <br /> CITY STATE ZIP <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER® FACILRYIBUSINESSEI THIRD PARTY BILLINGD <br /> BILLING AND COMN,IANCE ACK.NOW LEDGMENT: 1,the Yndmigms]APPIICanS Certify that 1 am die Onmer,Q RYmOr,A aMifiTLd Agenr,ar RexPWRIA/e PaM and 1 ael moWkd,Nar all P.ViT FThT, <br /> PENALnES,E.YP)RCLNLYT CHARGES eM/ar HOURLY CHARGES associated With this project will be billed IO meal the address IdeaYfied above as the ACYDT/NTAnneLSS for this silo, f also mr iry that aB <br /> information prmMed on rhes application h true mtl mrrxy end the[all regulate0 activities Will ue yerfonoed iu mwtlenee with as applkahk SAN JowpwG COE4fY OWILVAYCE CODE,esu1,'or <br /> STANDARDS so STATE Rattler FEDEROL LAWS and REGULATIONS. As the andertigned Hans,,Opera MY,Awhonzo Age i,w KCS rajjNe Parry fw tha n jiat Netted there mow faellit/dIt Widress,I <br /> hereby inflan lze the release of em cad all rasulD,reports,mad other enviramnenM assessment infnrmvtFm m SAN JnADLNN COUNTY K. RONMfiMAL TI DEPA¢En IE1f saoo es M 6 available <br /> and at the same time it 6 provided to me or my reprERwmlive. <br /> APPILCN?NAME(PfEASEPRIW) Victor Aranda SIGNATURE <br /> Z <br /> TRIS Owner TAXIDN <br /> APPDOIFOBY DALE ACCOUNTING ORICEPRGDF.B&NO CDYNEIEO BY DATE <br /> $REMTOATON AMWMT PMO DATE OF PAYMENT PAYMENT TYPE RECEVr0 CHEF # RECEIVED BY WORK PLAN PE <br /> FEE:= <br />