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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHAnazSrcwm5FOR EHD USE ONLY OWNER ID# v9Q1 7:Z "ASE"' <br /> OWNER FILE <br /> COMPLETE THE FOLLOW/NG BUSINESS OW N E R PNFORMA HON: CHECK IF OWNER C(/RROYRrov,FILE wirHEH0 <br /> BUSINE88Ardex, LP PHONE`724-203-5000 <br /> I $ First _ M111 Lr.Tt -- -- <br /> BUSINESS NAME(NdMenenilromOwnerNeme) SOC SBC ofTex ro# <br /> OWNER'S HOMEADDREss 400 Ardex Park Drive <br /> CITMAliquippa STATEP ZF 15001 <br /> OWNER'SMAILING AODREss(If 3f renttrom Qwnre,s Address) AbweJ n x,Cera of <br /> 2612 Station Drive Marshal(Seavers,Plant Manager <br /> MAIL'NG AnoRESS CITY Stockton cSTATE °95215 <br /> TYPEoi,ONNFASHIR: <br /> CORPORATION❑Q INDIWIXIAL❑ PARTNERSHIP❑ LOCALAGENCY❑ COUNTYAGWOY❑ STATE AGENCY El FEOAOENcY❑ CITHER❑ <br /> FACILITY FILE <br /> FACILITYID#: ' _x „l. - :'� CO-OWNERID#: ACCWNTID#: <br /> CompLETETHEFoLLowrNG BUSINESS FACILITY/NFORMAnom <br /> [11S this a NEW Business LOCATION or VEHICLE notpreviously regulated by the ENVIRONtENrALHmTH DEPARTMENT? YE5 Nos this an EIrsTiNG Business LocAnON but a NEw THE of regulated Business? YES ❑ No <br /> BuSINEssfFAcarTY NAME(Thm will be the BLd/va49 NAaE°"tf> HEALTH PERMtrj Ardex Stockton Plant p'' b� <br /> FACILRYAODRESS(HFACK isa MosttEFOJOUNlrer FCOo VeHictEn fMBCIXAMSSARYAnnRFS St pyStNESs PHONE <br /> 2612 Station Drive e163't� <br /> Sue# <br /> CITY(ffFAcr/ isa mas FavDuNrr°r FOODVEncLEuse theC mmissaaYStOCktOn STATE CA ZIP 95215 <br /> BOAROOFSl11POWISORDISMMJ'� l LOCATIOM COQ KEY 1 KEYL <br /> MAILM ADDRESS fOlrHeaM PBnnff(If OIFFERfHTfrom FacMyAoMress) Athi"a°"arcare of Marshall Seavers,Plant Manager ' <br /> 2612 Station Drive <br /> MAILING ADOREss CITY Stockton ST"T�CA Z"95215 <br /> SIC Core: AEN« D 3 L I <br /> AG.ffA0QW_SS forfees and charges: OWNER ❑ FACILITY/BUS)NESS ❑■ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: [,the undersigned Appllcamt certify that I am the Owner,Operator,or Authorized Agent of this Business,and I <br /> acknowledge,that all PER n`FEES, PENALTIES, ENFORCEMENT CHARGE and(or HOURLY CHARGES associated with this operation will be billed to me at the <br /> address identified above as the AOCOUNTAOORESS for this site. I also certify that all information provided on this application is true and correct;and that all <br /> regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNN Ordinance Codes and/or Standards and STATE and/or FEDERAL <br /> Laws and Regulations. <br /> APPLICANT'S NAME' Marshall Seavers; SIGNATURE' <br /> Pnik <br /> TrrPlease <br /> Manager LE: Plant Mana DATE ORNER'SIJf:ENSE# <br /> n g pHOTocovr ReoulREo <br /> ApproYad By K t/� °r'12 I I,. A«�e nn oma.Praa..nsoomPtamd ar oam <br /> A PROGRAM{EHD 48-02-034 Pink}or WATER SYSTEM{EHD 4602-0031 fano must be completed for each EHD regulated operation at this LOCATION <br /> except UST Program(Use SWRCB forms) <br /> EHO 41-02-035 Mastefile Record-Green <br /> 11;27107 <br />