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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE 04/11/2013 MASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> SITE MITIGATION&LOP <br /> €G DWNmloM c .S�as 670/3 UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CNRsNNOWIVER/S CWTAUDolYONFAX MTTTa EHDE3 <br /> 7OWNN'ERMMUNGAOMM <br /> OWNER NAME Victor Aranda 209) 464-8675 <br /> FMST MI LAST PIIOtM NUImde <br /> NAME E-YAILADDRESS <br /> N/A N/A <br /> MEADOpESe <br /> 87 East Marsh Street <br /> Stockton aT"re m <br /> CA 95215 <br /> 1318 East Scotts Avenue <br /> NAILWD ADDRESSCm <br /> Stockton aT"re ZIP <br /> CA 95205 <br /> ❑CORPORATIXI ❑INDIVIDUAL 11 PARTNERSHIP <br /> ❑GOVFANMFMAOEil4ry ®REEPONLBIE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNYA CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP X <br /> FAOILm IDM INVM ACCOUNT ID PR ROM AaAGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB_DTSC_EPA_ <br /> 34Y 3-7 <br /> FACILITY FILE:COMPLETE BUSINESS ISITEI PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BYTHE ENVIRONMENTAL HEALTH DEPARTMENT? YES C1NO <br /> IS THIS AN EKISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ® No <br /> BUMEIsa/FACIu ISmRRMIC NAME <br /> Former Ocam o Pro erty <br /> Erre AOOREsBIPRGEDTLocanoH SImEM BuS&ESS PI <br /> 821 South Wilson Way <br /> CITY Stockton CRTATE ZP <br /> 95205 <br /> BOAROOFSUPERVISORD(STRICT LO rhni CmE KEPT KEY2 <br /> MAIDNO Amomses,IF DIFFERENT FROM FACILmAOOREIs ATTENTION:CRCARE OF(CPINMML) <br /> 1318 Scotts Avenue Victor Aranda <br /> MAILING ADDRESS Cm <br /> Stockton STATE aP <br /> CA 95205 <br /> SIC CODE APNM COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIREDABOVE. <br /> BUSINESS NAME ATTERRON:oRCN1E OF(OP}KM(aL) <br /> MAILINOADDRem, <br /> PHONE <br /> Cm STATE ZJP <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER® FACILITY/BUSINEGS❑ THIRD PARTY BILLING(] <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,Nle unde'nignld Appli Ont,certify that I sin Ne Owner,Opemro/, or Re,,ala%bk PoGy and I acknowledge that all PERMf/f�6, <br /> PENALTIES,ENfORCGNEYIC/GRGAS andhow HOURUCHARGEle associated with this pmjttt Nill be billed 19 Neat the 2tldr65 identified shove As the ACCUUNTAODREf for thu sO,I aho certify that ad <br /> informadav provided Dv this app1ha5on B true and eorrectt and that via leguland mlividin rill be performed is accordance with ad spplkobk SAN JOAQUIN COL.ttv OROLR.GNCE CODES and/or <br /> STAYDAINGand STATE endear FEDERAL UYS and RE6ELAnONS.As tM1e undersigned Owner,OpemwAAvrbonaMAgmt,or Re pansibfe Parry for the pmJect fouled shove undn facility/site atltlrtss,t <br /> hereby authoriac Me release of any and ad resWb,report,and-her enviromneahl vssesenwat infoOnate.to SAY JoAQM. COUNTY F.mAaawsENTAL NGLnI DEPARID '•c s sons M it h avaeable <br /> and at the same fine it u provided to..or my rep.s.d.1ive. / <br /> APPLICANT NAME(PLEASE PRINT) Victor Aranda SIGNATURE <br /> TITLE Owner — <br /> TAII ID M <br /> API>ROrEOBY DATE Ac a NGNco TwEPRoe"1 wcDMF E EDe DA E a3 /3 <br /> SITE MiT1 T H AMOUNT PATO DATE OF PAYMENT PAYMENT TYPE RECEIpTM CHEGN M <br /> FEE:; RECEIVED 6Y WORxPuia PE <br />