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<br /> DATE — GREEN FORM
<br /> MASTER FILE RECORD INFORMArroN "MFR"
<br /> $HA�C�AIIE/I FON END.116E Dntr r � '
<br /> UNIT iv
<br /> OWNER FILE
<br /> lam-a-Te THEF0LL0WArJVGPR0PERTY OWNER XNFORMAzrm. CHECrrIF OWNI'R CURRENTL YON FILE WnN EHD ❑
<br /> PROPERTY OWNER PHONE
<br /> NAME
<br /> First M! last
<br /> BusiNESS NAME +'^
<br /> �✓� J/ `� �nC A ,- ,- SOC SEC/TAX ID#
<br /> Owner Horne Address V DRIVER'S LICENSE#
<br /> City 54y / STATE ZIP
<br /> Owner.MailingAdd
<br />-'-
<br /> ailing Address City 3l Sta'ea.— Zip CTS O2
<br /> TYPE OF OWNERSHIP
<br /> CORPORATION❑ INDMDUAL 0 PARTNER.SMP❑ FED AGENCY❑ OTHER❑
<br /> FACILITY FILE
<br /> 0! Kevin P.
<br /> DoughertynD
<br /> 1I
<br /> u ll n
<br /> Is Dougherty Properties f i- 1 C_ L-'J v_ ) No
<br /> I,
<br />!s 2920 Pacific Ave. 1001 No ❑
<br />— Stockton, Ca 95204 FEB 2 2001 so-zsssnztt
<br /> Bl _ DATE '
<br /> S c
<br /> PAY 7'0 THE ��.�[j���l�'
<br />—z ORDEjti�F �t+PHlv](JI1lM�I'JTHEA .,,,.,,.,,,.,,.,
<br /> 51 FC ,' 7�' r-✓ g BUSINESS PHONE
<br /> ��c T/SERV(�CES �� ��/ .,,r, ....,,.,..,.~....,..,a.,,., f�$fi� d�z�
<br /> ' /cv�j c
<br /> Cm ��� /� FACE OFORIGINAL DOCUMENT HASACO ED BACKGROUND ON WHITE PAPER:DOLLARS ZIP
<br /> Bank of Agriculture &Commerce' pp���]
<br /> Stockton,CA 209-944-1814 ate -
<br /> MEMO F(opub-0
<br /> 1: 1 2 1 1 2 S660j: 100 1 010 2 269911' _ "'
<br /> ZIPf
<br /> THIRD PARTY BILLING INFO: Completeif Billing Party.isdifierentfrom Property Owner or Facility Operator identffiedabove,
<br /> BusUNEss NAME i /� i/`� Attention:or Care Of (optional)
<br /> Mailing Address ��j ) r, /�/L�f A J� PHONE';/3 Cay
<br /> CITY C ��y. //�,a.. - STATE C� ZIP ��J o
<br /> ACC_OVNTAooi�,�S for fees and.charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING
<br />:I1,LING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERAAr FEES,
<br />'LNALTIES,ENFORCEMENT CILIRGES and/or HOURLY CHARGES associated with this operation will be billed to me At the address identified above as the ACCOUYTADDRES.0 for this site. I also certify that all
<br /> iformaiioa provided on thus 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 /> wadards and STATE and/or FeDeRAL Law&and Regulations. As the undersigned owner,operator,or agent of the property located at the above faglity/site address,I hereby authorize the rdcasc of
<br /> uy and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION as soon a it is available and at the same time it is rovided to
<br /> ac or my representative- -
<br /> PLeAs;,Phurfr
<br /> APPLICANT NAME �V, 0_4
<br /> / SIGNATURE ✓�-
<br /> TITLE `����J1ZC''�Z/ G C C L JZ f� DRIVER'SENSE/f t F / 3 7 (/
<br /> V ,J PHOTOCOPYOCOPY REQUIRED
<br />
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