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San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE March lo, 2009 MASTER FILE RECORD INFORMATION "MFR" <br /> a UNIT IV <br /> SHADED AREAE FOR EHD USE ONLY OWNER If CASE# <br /> OVMER FILE <br /> CHECK Ii OWNER CURRENTLYON FILEHIIH EHD ❑ <br /> COMPLETETHEFOLLOW(NGPROPERTY OWNER INFORMATION: <br /> PRppERTyOWNERNAME Mike Santin PHONE 760-219-0111 <br /> First MI Last <br /> SocSEc/TAXID# 554-51-6536 <br /> BUSINESS NAME <br /> Owner Home Address ---------------- <br /> 46775 Mountain Lane <br /> DRIVER'sUCENSEII H0176903 <br /> STATE CA ZIP 92210 <br /> City Indian Wells <br /> OwnarMaikngAddress Same as above <br /> State LP <br /> Mailing Address City <br /> CORPORATION ElINDMDUAL <br /> PARTNERSHIP❑ FED AGENCY ElOTHER[I <br /> FACILITY FILE <br /> E---Lr:r, <br /> ID# <br /> CROs REF ID# ACCOUNT IDN INV# <br /> COMPLETE THE FOLLOWING BUSINESS/FACILITY I SITE INFORMATION.' <br /> IS this a NEW Business LOCATION not PI'eVIOUsIy regulated by the ENVIRONMENTAL HEALTH DEPT.? <br /> YES ❑ No <br /> is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YEs ❑ No ❑ <br /> BUSINEssIFACItm/SrtENArAE Stockton Cadillac <br /> $UrrE# BUSINESS PRONE 76(D-219-0111 <br /> SITE ADDRESS 3190 Auto Center Circle <br /> Cm Stockton STATE CA ZIP 95202 <br /> BOARD OF SuPERV1stR DIFTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address NDIFFERENTSamFao/l/tyAddress Attention:or Care Of(opNa►a/1 <br /> STATE ZIP <br /> Melling Address City <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete ifBiIli ng Party is different from Property Owner or Facility Operator identified above. <br /> Attention:orCare Of(tlptkVW/1 <br /> BUSINES8 NAME <br /> PHONE <br /> Melling Address <br /> STATE ZIP <br /> CITY <br /> ACcouATJ9DORE39 for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledg that all PE2NIT Fees, <br /> PENALTIES,ENFORCE.MENTCH/ARGFS and/or HoURLYCHARGES associated with this operation will be billed tome at the address identified above as the ACCOUNTADDRtss for th' te. I 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 CO finance Codes and/or <br /> Standards and ST.AFE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address a uthorize the release of <br /> any and all results and environmental assessment inf r do o SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR soon as it is ai le d at the same time it is <br /> provided to me or my represen tiv. <br /> SE PRIM SIGNATUR <br /> n n <br /> APPLICANT NAME �-+` <br /> DRIVER'S LICENSE# <br /> TITLE -I ` r 5rG.�f <br /> o t l � ' `�` t ��f 4 1 PHOTOCOPY RED C• <br /> Approved By Date Acooun.ng Office Proceeeing Completed ay Da6e <br /> 29-02 10/12/07 MASTER FILE RECORD-GREEN <br />