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San Joa uin County blic Health Services Environmen +iealth Division <br /> ' GREEN FORM <br /> DATE r Z .0 MASTER FILE RECORD INFORMATION "MFR" 6ReeIllil <br /> nR. DWNERID# ry/ �t/Sl CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NG PROPERTY OWNER INFORMATION., CHEcKn, OWNER CURRENTL YON Fac WITH EHD <br /> PROPERTY OWNER �M PHON fz:!� INV (s <br /> NAME i , , L qq <br /> First MI last {R0� <br /> BUSINESS NAME SOC SEC/TAX ID If <br /> SAN JOAQUIN VALLEY ASSOCIATES <br /> Owner Home Address 2333 SAN RAMON VALLEY BLVD DRIVER'S LICENSE# <br /> city SAN RAMON STATE CA ZIP 94903 <br /> vsswisvr� <br /> U `—IO State Zip 5� <br /> (:nRPn RGTInNI r-I NnIVInY1y�1G1 ❑ PLRTNFRCXIP FFn All.,.v❑ OTHF.❑ <br /> Fefll civ n tk �� ✓ (:RnCc RFF Nl R AIJC INT In C <br /> COMPLETE THE FOLLOWING BUSINESS/ FACILITY/SITE INFORMATION: <br /> ISthi3 a NEW Business LOCATION notpreviously regulated bythe ENVIRONMENTAL HEALTH DIVISION? YES ❑ NOR <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO Kx <br /> BUSINESS/FACILITY/SITE NAMEN A <br /> BRIDGEPORT TRATUS DEVELOPMENT - 1 S AKAew <br /> SITE ADDRESS _ i. / /•, �M E# AUSINERS PHONE <br /> CITY STOCKTON / SSTTAAATTTE CA Z 95206 <br /> BOARD OF SUPERVISOR DISTRICT I I LOCATION CODE IKEY1 I - ( KEY2 I II <br /> Mailing Address WDIFFERENT from Foci/ityAddress Attention:or Care Of(opb'ona/) <br /> Mailing Address City STATE ZIP <br /> SIC CnnF APN M Cnmm.NT- <br /> THIRD PARTY BILLING INFO; Complete if Billing Party is differentfrom Property Owner Or Facility Operator identified above. <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> GLEN SPRTNGS HOLDINGS, INC. KEN PRICE <br /> Mailing Address PHONE <br /> Civ STATE KY LP 40509 <br /> �:TI�T^ - <br /> ACCOUNTAnnRESS fnr fans and rharans OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> R I A iNn ANn ComvI.IANcE AcxNowl FnnmaNT; I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES assodaled with this operation will be billed to meal the address Identified above as the ArrOuyFAUoRFC.G for this Site. 1 also certify that all <br /> information provided on this 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 /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorise the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the Same time it is provided to <br /> me or my representative. <br /> PLEASE PRINT j' r <br /> APPLICANT NAW (A, ' u71� SIGNATURE PYTN=d.� CNV(VdK W�y""t �a� <br /> - DRIVER'S LICENSE It <br /> TITLE <br /> Annroved BY nates Aermmtinn OHinrt Pmnaseinn r. m-Ifni R. <br />