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San Joaquin Courity Environmental Health Department <br /> DATE GREEN FORM <br /> MASTER FILE RECORD INFORMATION "MFR" <br /> gnaw <br /> pnnuc�res, UNIT IV <br /> OWNER FILE <br /> COMPLETE 7HEFOLL014INO PROPERTY OWNER INFORMATION, Ckfmf OWNER CVRRENRYONFI N7rY END <br /> PRopnittOwnER NAME GURPRETT <br /> DHATT PHONE <br /> First Ml Last <br /> BUSINESS NAME <br /> SocSEC/TAX ID# <br /> Omer Home Address 11287 NORTH LOWER SACRAMENTO RD. DRIYERSLICETfsE# <br /> City LODI S'"1e CA 95242 <br /> Owner Mailing Address 11287 NORTH LOWER SACRAMENTO RD. <br /> Mailing Address City LODI 'abeC.A 7jP 95242 <br /> TysamnaaNFRs D ' <br /> CORPa+nTiaa❑ INDMWAL� PARTNEPSIDP❑ <br /> FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> fAmrTY ID# CROSS REF ID# ACCOUNT ID# INV# <br /> E LL N N MAR <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No . <br /> Is this an EXISTING Business LOCATION but a Nm TYPE of regulated Business? YES ❑ No <br /> BusINEss/FAmIiY/$HE NAME <br /> SITEADDRESS 225 S. CHEROKEE LANE StJ E# Bustress PHONE <br /> CITY LODI STATE <br /> CA Zo` 95242 <br /> Mailing Address ifDIFFERENTfrom Fad/ityAddreu Attention:or Care Of Int.6-Sto <br /> PLACECROW CANYON # 150 ATLANTIC RICHFIELD CO. <br /> Mailing Address City SAN RAMON STATE CA '" 94583 <br /> 77 <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is d/tferentfrom Property Owner orFacility,Operator identified above. <br /> BUSINESS NAME ATLANTIC RICHFIELD COMPANY Attention:wCane Of (opbontai) <br /> SECOR <br /> Mailing Address 3017 KILGORE ROAD # 100 PHONE 916-861 -0400 <br /> Cm RANCHO CORDOVA STATE CA Z" 95670 <br /> AcxQuairAgagil for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> aaaaaaaaa <br /> BILLING AND C : 1,the undersigned Applicant,certify that 1 am the owner,Operator,or Authorized Agent of this Business,and I acknowledge that all P£Rnnr FEES, <br /> P£NSL1ru'ENFORCE&,ENTCH,tRGSS and/or HOUE£YCHARGEs associated with this operation will be billed tome at the address identified above as the AmonxrAnnRvev for this site. 1 also certify that <br /> all 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 ofthe property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> yrovided to me or my representative. <br /> APPLICANT NAME _I o A-1' P�P� SIGNATURE/ <br /> 11 r PTI` \_ ._.... <br /> TIRE <br /> , DRIVER'S LICENSE N t,',RSJ M e.. 1A L Xo3i,-i ' ; Gid wroYRQU <br /> APPrrNed I)y Date AamussUlg Olfice Pmressin9 CompletrA BY Dale <br /> 29-02-002 April 25,2003 <br />