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10/26/1999 15:04 20953858 <br /> OLOGICAL TECH TCS PAGE 03103 <br /> . �... <br /> I 1 . � <br /> !0- <br /> GREEN FORM <br /> DATE " MASTER FILE RECORD INFORMATION MFR6-1999 UNIT IV <br /> SHAPED AREAS FOR END USE IM 0 <br /> OWNER FILE <br /> CoAllI7'Hr FoLtOWING PROPERTY <br /> OWNER INFORMAT/ON: CNEflKlF OWIJERCda�wrrYaNFrLEwirA1EHD <br /> PHONE 209_471 -1 787 <br /> PROPERTY ,Terry DeGroot <br /> OWNrR NAME <br /> r� <br /> :. <br /> xI mar �,� <br /> SOC sEc 1 Tax ID# O O U&.Z <br /> ottelwass NAM! V <br /> �. DeGroot & Sons a California General Per n r 1 <br /> T <br /> DRIVER's LICENSE tt L&IS-7 , 1 <br /> Owner Home Address 908 Ruby <br /> STATE ZIP 1 <br /> City Rlporl r L <br /> OW„sr MRlline Address �, `.-i�u t ' <br /> (� State CAZip <br /> Mailing Address City 92-, <br /> Fen AOPN6Y THER <br /> F-0.11-ORATIOND PARTNERSHIrn <br /> FACILITY FILE - <br /> _ o <br /> CO�IfPLETETHEFOLLOW/NG BUSINESS I FACILITY I SITE INFORMATION_ Yn No �; t <br /> Is ttlis a NEW Rusinese La6AmoN not previously regulated by the ENWRONUENYAt HEALTH DIVISION? Yes © NO <br /> is this an EXI8TIN0 Businosa LOCATI,00 but a NEW TYPE of regulotod au sineas Y <br /> BUjjNEESJFACILnYiSrTe NAME <br /> SUITE# BU811IPHONE <br /> SITE ADORESBI <br /> 13737 South Airport Way (APN#198-03-3) <br /> STATECA <br /> ZIP 95336 <br /> CayyMantec111 <br /> 11 <br /> a <br /> {t7fuk2 I (@(! �YsGtpy� n �st�rI'ki <br /> MO , SNINE g21, � <br /> Attention: or Care Of(optional) <br /> Meiling Addrsas ifoIFFERENTfrom FecllityAddraee <br /> STAYS Zip <br /> Mailing Address City <br /> TRtRO PARTY BILLING INROp Compieteif Billing Party is different from Property Owner or Facility Operator idenErIahove_ <br /> Attention: or Care Of (option# <br /> BUSINESS NAME <br /> TPII <br /> Mailidg Addreaa <br /> STATE ZIP <br /> CITY <br /> Ess for fees and cha es OWNER FAciuTY/C3USINESS THIRD PARTY BILLING <br /> BILL[No AND .0"T„rANcE AcKPOwLrDQmVNT: 1,tine aadantgnea Applieank,cerHry that I am the Owner,Op or,or nlufHorlaed Agee!of this Business,■rad 1 acknowledge that all <br /> PVMtrrFMS,PdNALMW,ENFoAco[ENr CmARGEs and/or)70V r CN.tRflaS associated with this operation will he billed to me at the address IdentlileA above as the r11C0oUNTADDt[8ST <br /> for$is site. I also tertKY that all infbrl"MO a provided on this applicatioq Is true and correct;and that all regulated emivitica wW he performed in accordance with all appricable SAN <br /> JIaAQaIN C VNW OrdlaaDce Codes and/or Standards and STATr,sudlor WitusRA.L Laws and Rcg■latians. As the undersigned awner,operator,or Agent of the property located at the <br /> above racility/site address, I kereby auxaorim the release of any mw all remits and environmental asSM110cut infarmAtiea to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DIVISION As 5000 As it is available and at the game time it is provided to me or my reprraentbtive. <br /> PLE W PRINT <br /> APPLICANT NAME C.. D'eGroo.t & Sons SIGNA3110. ... <br /> DRIVE'R'S LICENSE E b 0 X 3 35—7' <br /> TITLE Partner ipwo'rocoPX pWI11gFF1L <br /> - Ir <br /> 'a <br /> 6.) <br /> V -d <br />