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10/26/1999 15: 04 20953858r-'� GEOLOGICAL TECH ' S PAGE 02/03 <br /> NOW <br /> � <br /> DATE 1 0-26-1 9l9li MASTER FILE RECORD• INFORMATION "MFR" GREEN FORM <br /> wI1�Po�ARIAS POR EMD ME ONLY UNIT IV <br /> OWNER FILE ,Y <br /> COMPLETEFTHE FOLLOWIA10PROPERTY OWNER /NFORMAT/ON; CHECK1F OWNER CbagpNTLVON FILE MTJYEHO <br /> PROPERTY PHONE <br /> 0"GRNAME Jerry DeGroot 209-471 -1787 <br /> Fft <br /> BUSINF33 NAME goo Src I TAX ID# <br /> 4 <br /> C. DeGroot & Sons ;tel - dC)0 <br /> Owner Home Address DRIVER'B LICENSE# S+7 <br /> 9019 Rnhy Court city Ripon STATE CA 7Z'P 95366-2258 <br /> T <br /> Ownx Maillnp Addro» ``. <br /> { ' lT <br /> Mailing Address City �Z\ 3tata v dip 3 <br /> CORPORATION El INDIVIDUALD PARTNCRbkl FEU AGENCY C7H[ I� <br /> FACILITY FILL' <br /> COMPLE'TETIYEFOLLow1A(G BUSINESS/ FACILITY/SITE/NFORMATIoN; �A <br /> Is this a NIw Boalness LOCATION not previously regulated by the ENVIRONMENTAL 149ALTH DIv161oN 7 Yes ❑ NO I]S!J <br /> Ia IhIS an EXISTING Business LOCATION but a NEW TYPE of regulated Business 7 YES © NO tl7oi—n, r_I <br /> BUSINEWFACIILrY/SITE NAME <br /> SITE ADDRESS SUITE# gU6MtE88P"ONS <br /> 14253 South Airport Way (APN#198-03-4) ) ; ^7 � 7 <br /> CITY Manteca STATE CA LO 95336 <br /> i-tl3' j�lEl{i E ..fP I ...•n t41W E .. � n <�, ..._ :. u E 8 - ]2 ttmi tall fl <br /> Mailing Address ifD/FFERENTIYom Fwoll/fyAddrves Attention: or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> ta M21 MR, ON OEM_ <br /> THIRD PARTY BILLING INFO: Comp)®teif Billing Party isdh%rentfrom Property Owner orFacility Operator 1dentffledabove. <br /> BUSINEss NAME Attention:orCare Of (options# <br /> Mailing Addreas <br /> PHONE <br /> CITY STATE ZIP <br /> ACQQLWTAgfffW for fees and charges OWNER FACILITYISUSINESS THIRD PAKTM BILLING <br /> B1t t 1HG ANP GoMrLiANct ACK1iowLa'DaMEN r: 1,the undentgatd Applicant,certiry that I am the Ownar,Operotor,or Asdhorized Ageni of this Business,and I aclmowiedge that all <br /> PeklstrFkz14 Pa,Eur rrlw9,rNF0Ait,W4MT CAZWJS and/or,florinyCNAEt M associated with this opersidon will be bAlcd to ate at the address identified above as the A onrr DD s <br /> for this site. f also certify that All information provided on this application is true and rota;and that ail regulated activities will be ptrfe med to Acoordanee with all applicable W <br /> JOAQURI COVMW Ordinance Codes and/or Standards sad STATE andlor FILM RAL].Awa and Regulations. As the Undersigned owner,operator or agent of the property located At the <br /> above tetlllty/Slte oddtraa, I hereby amtherize the relent of&;Ay sled 1111 mults and environmental assetgmoat Wormation to SAWN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DIVISION as Boon as it is available and at the,Same time it is provided to roe or my MpMeatativr. <br /> PLEASE PRINT <br /> APPLICANTNAME C. DeGroot & Sons SIGNATURE <br /> TITLE Partner DRIVER'fPHQT000 LICENSE_# n O�S 7 / <br /> IpHOTO00PV REOUIREDI .v <br /> V d iASZ-0 I. <br />