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<br /> DATE 006,433 MASTER FILE RECORD INFORMATION FORM (EHOGIS(REVrsa:nne11,r9T)
<br /> UNIT IV
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<br /> Buyer OWNER FILE
<br /> COMPLETETHEFOLLOWING BUSINESS�#ER-INFORMATION. CHECKIF OWNER CURRENrtrONFRBwrrNEHO Q
<br /> BUSINESS Joe E Barnabee PHONE
<br /> OWNER NAME _�_ ��— ( 21 3 ) 262-5145
<br /> Fm Let Last
<br /> BUSINESS NAME(if dit9rentf—OWnerName) Rehrig Pacific Company SocSEc/TAz10ii
<br /> OWNER HOME ADDRESS 4010 E. 26th Street DRIVER'S LICENSE#
<br /> a1r Los Angeles FATE CA ZIP 90023
<br /> OWNER MAILING ADDRESS (if OIFFERENTfi cm OwvrerAddress) Action:orCare of (opt )
<br /> Mailing Address City State zip
<br /> CORPORATION i7 INDIVIDUAL Q PARTNERSHIP Q LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY Q OTHER❑
<br /> FACILITY FILE
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<br /> COMPLETE THEFOLLOWING BUSINESS 1 FACILITY/SITE INFORMATION:
<br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH 01VISIoN 7 YES ❑ No Q
<br /> Is this an Em STING Business LOCATION but NEIN TYPE of regulated Business 7 YES 13 NO
<br /> BUsiNEss/FACILITY/SrrENAME Fortifiber
<br /> SITE ADDRESS 501 E. Acacia Street ` Sun-E# BUSINESS PHONE
<br /> CITY Tracy STATECA ZIP
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<br /> Mailing Address ifOIFFERENTfrom Fac&*Addrass (Property Owner) Attnntltxr or Cane Of(aptioaal)
<br /> Fonzia Corp. 1001 Tahoe Blvd.
<br /> Mailing Address City Incline Village �Y sTATECA xP89451 -9512
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<br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is differentfrom Business Owner Identified above(
<br /> BUSINESS NAME AMentlon'arCare Of (opdorsal) fJL»y YI YIV
<br /> (U6�.���,'L(c�},$��h>OW—
<br /> Mailing Address2 7 41___Ri v__e,r__Rd._ O / T n(�Q/ PHONE
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<br /> c� 5 /J i STATE , zip 95-351
<br /> ACCOUNrAOVREW for fees and Cttarges OWNER FAcam/BusiNEss Treem PARTY BeiING
<br /> BILLlyr:>ND COhiPLIANCE ACKNOwLEDGMFP[T I,the undersigned Applicant certify that I am the Owner,Operator,or:irthazrd Agent of this Business,and I acimowledge that all
<br /> Pmwr FEES. P1-;"GL=, F-vFoRcz3Q'Nr CHARGIM and/or HOURLY QTARCFS associated with this operation will be billed to we at the address identified above as the Acccav'
<br /> .ADDRESS for this site. I also certify that all information provided on this application is true and correct and that ail regulated activities will be performed in accordance with all
<br /> applicable SANJoAQuu4 Cott`w 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 JOAQLgN COUNTY
<br /> EYVIRONVL Ei iTAL HEALECLS,
<br /> K as soon as it is available and at the same time it is provided to me or my representative
<br /> Pt.EASE P NT
<br /> APPLICANT NAME O I10 Lt) SIGNATURE �z
<br /> TITLE v DRIVER'S LICENSE f Not-Z6 a10"
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