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GREEN FORM <br /> AT'E MAS tR FILE RECORD INFORMATION "MFR" <br /> es,,,en.rtrl�tNtluoeo,., " _ '.� UNIT IV <br /> OWNEIR FILE <br /> rMPLE7rThHPfoLt.0m NG PROPERTY OWNER lwoRMATJ m, C1,1,!!PKw OWNER 0--f7rrzr0Nr&EWrHEHD ❑ <br /> �ttorl:RTT - Prto«c <br /> lNt7(NAME <br /> ra � <br /> I?ft-=NAMF LBPOE of W. Lodge 10115 SxsGCITAXIDO <br /> wner Home Address Dmvews LICEKsER <br /> STATE ZJP <br /> wtar Mta+ar+9 nuar„f P O.BOX 691985 <br /> Ing Address City Stockton State CA Z}p 95269 <br /> 'l7MT1,0H Q Mtviv+owl.Q PArrIYIERSH1P❑ ,., FED AGEHCr'❑ OTHER 12 <br /> FACILITY DILE <br /> .i:nrL- r,�,, Ii�F[5:' ,7:t1.>rf. UtT �+'� .l; ➢`'. `�” .-., :�11 <br /> --I",�^ <br /> TPL=7WEF01L0WING BUSINESS I FACILITY 1 SITE hVFORMA7-I0A1' <br /> is a NEw Susiness LOCATION riot previously regulated by the EWRONMEWAI Mrm DTVI aN? Yes :b No <br /> this an EmSTtNG Business Locxnoo;but a NEW TYPE of regulated 6u3ITV33 7 YES p No <br /> NESSIFACt1.ITYISITE NAME N/A <br /> rrEAnoREss 315 S. Center Ave - Suilf0 Bus**BLPNotIE <br /> N/A <br /> I <br /> Stockton STATE CA ZIP 95.212 <br /> c�y_/�.�r� s R '• t�' " � <br /> ng Addreoa 1fD1FFFRMVT from FwaiW Ado$-~ Att,antlan- or Care Of foplionsp <br /> ng Address.City STATE LP <br /> S �" 3'�� .�A3j'2�i' ;Tr-ae.Jt. ,w.�-'�.�ji'ire.•`-"y+�1:�--+✓�. .v yc4: <br /> •. ,, °rie d!"'�ef---r:2-r'� ,.;• '� 3 i�i. f.:$.'.c`;3.-n �rY� ..�a-.,:� .��V <br /> 1!-D PARTY 13ILLINO INFO: Complete if Billing Party /S d/flerent from Property Owner or Facility Operator/0elirt/I7eal aDove. <br /> 4VM NAME Attention:or Care Of (optiarza/J <br /> CL Properties, VI Mr- Chris "=ac'- <br /> e"'ngAddren 6227 N. Fresno St. P+Io++E 559-437-1333 <br /> Fresno STATE CA ZJP 93720 <br /> s qUAMOME.W for fees and charges OWNER FACttm/BUSINEss Tr jRD PAIt'tY BILUNC <br /> I.IN(:AND rOMPlJANC,x A[IUIowLvbcmeNT: L the amdctsigaed Applicant.certify that 1 am the O*wcr,01wWor,or A0A0dzc d Aj!enrofthis heist,fwd I sdLa*wk4t*IbAt all <br /> "rrFZ"P&VaT7ST,ENFLMC 7Lf�7(7/AllGL4lnCfprifUt Rr.1 CHaaGLT ae #a red WfM thlf operation MII be MLed tome at the Wdress IdMtltkd above as IM A(tT)rNTADnJtVLV <br /> It silt I also certify 11th aii Inde naltton provided on this appl"don is tree and correct;and that all Tagmhstod ae ivilial raft be performed is mavrdyrkr with all aPptk*blc SAN <br /> llr <br /> ( v Cblry Ordla;ttite Codes amdlor Standards and STATL and/or FEDERAL LAvm sed Rcg■lalians. As the naderaigacd erTrer,operator,or aSewt of the pr►psrtp lastaf at the <br /> t. -■d6tyhtw address, I kmrhry aodmrim the rejc " or onj sad •R remIla and e"vironroewfol aseaeirniei Iwf4hMflloa to SAN •10A0VIN COITNTV ENVIRONM£NPAL <br /> �LLTH DIVISION as noon Is It Is Rvailrlbte and at the dale time It is provided W me or my reprtxeatativo- <br /> PLEAs> Ptv NT <br /> ICANr NAM / / � � SIGNATUREr! <br /> si fiil>�13Y.zJ-..tom.-i`f =r�.�.' :t7a#9.`•w-.. �`i +may` "4•i:n �U'Htoa�' -V.'-�:. --w n .}�'1'�'i't'r�:�- -aDlkRy���,<<.;� ,F".-- <br /> ■ <br /> TOTAL P.05 <br />