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San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE Marcn lo, 2009 MASTER FILE RECORD INFORMATION "MFR" <br /> - -=SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE <br /> CNECK/F OWNER CURRENTLYONFILEW/TH EHD❑ <br /> COMPLETETHEFOLLOW/NG PROPERTY OWN ER INFORMATION.' <br /> PROPERTY OWNER NAME Mike Santln PHONE 760-219-0111 <br /> First MI Last <br /> SOC SEC ITAxID# 554-51-6536 <br /> BUSINESS NAME <br /> Owner Home Address 46775 Mountain Lane DRIVER'SLICENSE# H0176903 <br /> city Indian Wells STATE CA ZIP 92210 <br /> Owner Mailing Address Same as above <br /> Mailing Address City State Zip <br /> FED AGENCY El OTHER <br /> CORPORATION❑ INDIVIDUAL® PARTNERSHIP El ❑ <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID# 11 ACCOUNT ID# INV# <br /> COMPLETETHEFOLLOW/NG BUSINESS/FACILITY I SITE INFORMATION.' <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FACILITY/SITENAME Stockton Cadillac <br /> SURE# BUSINESS PHONE 760-219-0111 <br /> SITE ADDRESS 3190 Auto Center Circle <br /> CITY Stockton STATE CA ZIP 95202 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYS KEY2 <br /> Mailing Address WDIFFERENTfrotn FaciiityAddress Attention:or Care Of(optional) <br /> STATE zip <br /> Mailing Address City <br /> ESI:CCOOE _��j APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Partner Engineering and Science Attention:orCare Of(option/) Kerran Pender <br /> Mailing Address 2101 Rosecrans Avenue, Suite 4270 =P..N- -962-4755 :�= <br /> STATE CA ZIP 90245 <br /> CITY El Segundo <br /> AccowATAOoeEas for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANcE ACKNOWLEDGMENT_: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMITFEES, <br /> PENALTIES,ENFORCEMENTCHARGES and/or HOURL Y CHARGES associated with this Operation will be billed to me at the address identified above as the ACCOONTAt)DRESY for this site. 1 also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME <br /> Kerran Pender PLEASE PRINT SIGNATURE <br /> DRIVER'S LICENSE# <br /> TITLE Environmental Scientist —(-PHOTOCOPY REQUIRED) <br /> FrApproved By pate Accounting Office Processing Completed By Date <br /> 29-02 10/12/07 mw MASTER FILE RECORD-GREEN <br />