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..::.....::.... :::..::...-.: <br /> .. .. q. <br /> . <br /> ta <br /> DATE MASTER FILE RECORD INFORMATION FORM {EH OO sS(REVISEo 0616 1197) <br /> . <br /> $MAOEO AREAG FOR EHOUtEONLT �Xy.. '�n y� y --- NIT IV <br /> V .......:' ....::'...... ::Ijl: .....:. <br /> Buyer y OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS O#I N&R-INFORMATION.' <br /> CHecx�FOWNERCuRRexrcronrFitewirHEHO ❑ <br /> ................................... <br /> . - <br /> .......... ...• <br /> PHONE <br /> BUSINESS Joe E Barnabee <br /> ( 21 3 ) 262-5145 <br /> OWNER NAME ----------------------- <br /> ......................................................... <br /> First .....Hl..._..-. Last.......................-.......... <br /> BUSINESS NAME(if different from owner Name) Rehrig Pacific Company E SoCSEC/TAxID# <br /> OWNER HOME ADDRESS 4010 E. 26th Street DwvER's LICENSE# <br /> Chy Los Angeles STATE CA zip 90023 <br /> OWNER MAILING ADDRESS (ifOIFFERENTfrom OwnerAddress) Attention:or Care of (opdonal) <br /> Mailing Address City State Zip <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> i;:;><l•it�i-#TY:I#�>#;::.; ;.:::.;::::.:::::::::...::.::.:::: ::,.t�fit758•IiE�.1€#.#::.......:.::.:,::.,.:::..::.....,. .:.COMPLETETHEFOLLOWING 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 1 YES ❑ No ❑ <br /> BUSINESSIFACIUTY/SITENAME Fortifiber <br /> SITE ADDRESS 501 E. Acacia Street SUITE# BUSINESS PHONE <br /> CITY Tracy - STATECA ZJP <br /> t <br /> Mailing Address dDIFFERENTfrom Facility Address (Property OwnerAttention:or Care Of(optional) <br /> Fonzia Corp. 1001 Tahoe Blvd, <br /> Mailing Address City Incline Village hY` STATEC,A 2189451 -9512 <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party /s different from Business Owner Identified above. <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> Geologi-Ea-1 Technics Inc. � �r,z , �� Ray Kablanow ��, �� I),rtu-k, <br /> Mailing Address 2 i V d. I •� .�� ( �\ PHONE ( 2 0 9 ) 538-6424 <br /> CITY Modesto L -x e- V—e sTATECA ` Z'P '95351 <br /> ACCOUNT AODREss for fees and charges OWNER FAC0.ITY/BUSINESS THIRD PARTY BILLING <br /> BTLLC C.�,'4D COMPLIANCE ACKNOWLEDGMENT: I,the undersigned applicant certify that I am the Owner,Operator,or Authorized Agent of this Business,and I ac"owledge that all <br /> PEKif77'FEES, PE-V L7TES, ENF0RC&11EN7"CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the,Arno,' <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 herebv authorize the release of any and all results and environmental assessment information to SAY JOAQUIN COUNTY <br /> ENVIRONNIE IT_L HEALTH DIVISIO`i as soon as it is available and at the same time it is provided to me or my representative. <br /> PLEASE P NT <br /> APPLICANT NAME D I(,�L�f�p(J� SIGNATURE <br /> 1 DRIVER'S LICENSE# O) <br /> TITLE v Tounrnrnov ecnrnacnl <br /> Approved<gyt -- irate", /Iteeottnt#ng'. <br /> t:. ' G3BIA <br /> :::... <br />