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U ftflf�.: .: : # C ::. fiIkk.: # S Er> t'C3 � :F'ltlt1�.>: i »: <br /> FORM {EH0015(REvtsEU06111t9 <br /> DATE MASTER FILE RECORD INFORMATION <br /> :::.. <br /> SHADED AREAE fOR�ttD UBE ONLY <br /> '�1y'W�'i�`�!�hy♦♦�y, y�.pl± -. NIT <br /> IV <br /> J:::4:CFi��tGA I ._. <br /> B�u�yv�e��r OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OSE-IRe INFORMATION: Cr+ECK/F OWNER CURRENTLY ON FILE WITHEHD <br /> ...................................................................................... <br /> BUSINESS Joe E ; Barnabee PH 1 <br /> ONE <br /> OWNER NAME --———————————————— ------- <br /> 2 3 ) 262 51 45 <br /> ............... ........................................Fimtl..............................................Las[ <br /> ........................................................ <br /> BUSINESS NAME(If different:from Owner Name) Rehr i g Pacific Company SOC sec/TAX ID# <br /> OWNER HOME ADDRESS 4010 E. 26th Street DRIVER'S LICENSE# <br /> City LOS Angeles i STATE CA ZIP 90023 <br /> OWNER MAILING ADDRESS (ifD/FFERENTfrom Owner Address) `: Attention:or Care of (optional) <br /> Mailing Address City State Zip <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> XX <br /> .::. <br /> .. <br /> ..:.>:::>; .:.;:::A>r�t>�s►tf#€fi#<: >'. ;; .<f ;. <br /> COMPLETETHEFOLLOW/NG BUSINESS / FACILITY / SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ NO ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO ❑ <br /> BUSINESS/FACILITY/SITE NAME Fortifiber <br /> SITE ADDRESS 501 E. Acacia Street SUITE# BUSINESS PHONE <br /> CITY Tracy STATECA ZIP <br /> ... ..:: <br /> Mailing Address ifDIFFERENTom Facility Address <br /> (Property Owner) <br /> fiAttention:or Care Of(optional) <br /> Fonzia Corp. 1001 Tahoe Blvd. <br /> Mailing Address City Incline Village STAT ECA Z189451 -9512 <br /> SNC CczDE. ;. ... <br /> THIRD PARTY BILLING INFORMATION. Complete/f Bllling Party /s different from Business Owner Identified above <br /> ............................................ <br /> ouslNEss NAME Attention:or Care Of (optional) <br /> Geological Technics Inc. Ray Kablanow <br /> Mailing Address 2741 River Rd. PHONE ( 2 0 9 ) 538-6424 <br /> Clrr Modesto STATE CA ZIP 95351 <br /> AG�QONT ADDRESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLfNC:vND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned applicant,certifv that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all <br /> PER.IHT FEES, PE.VALTTES, ENFORCE.IfENT CHARGES and/or HOURLY CIIARGES associated with this operation will be billed to me at the address identified above as the.ICCOtGyT <br /> ADDRESS for this site. I also certify that all information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all <br /> applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property <br /> located at the above facility/site address, I hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> PLEASE PT <br /> PCL, <br /> APPLICANT NAME � © � k0 SIGNATURE <br /> ' 1 _L? <br /> DRIVER'S LICENSE# i�► Q Q� <br /> TITLE /P"- <br /> .............. <br /> Approvesi 33�yt t#a#e Acct>tir:t#ng t3#fSae Pt-oaesstng�txt�piete(x :: ate.. .. <br />