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, t <br /> San .J0quin County Environmental Health0partment <br /> GREEN FORM <br /> DATE 11 03/10/05 MASTER FILE RECORD INFORMATION TTMFR" <br /> Snanm aaFac rna FHn uopnnv OWNER ID# 001ago?-- CASE# UNIT IV <br /> OWNER FILE <br /> COMP[tTE7NEFOLLOWINGPROPERTYOWNER INFORMATION: SAH JOAQUIN C0UNg4WKJy, OWNERLLwReNnYONMEWMEHD El <br /> PRopERrYOMEp NAME LTS Rentals LLC HEALTHDEPARTHEN P1Dm (209) 334-4102 <br /> First I MI Last <br /> Bnsuass NANE Soc SEs/TAx ID# <br /> US Rentals , LLC <br /> Owner Home Address 927 Black Diamond Way <br /> DRNER•S LECENSE:# <br /> car Lodi STATE CA 95241 <br /> Owner Mailing Address <br /> P.O. Box 1120 <br /> Mailing Address City Lodi I 'CA 'P 95241 <br /> CoRFonATmN�1 IN onnixi L❑ PARnaRAw❑ FEDAaeav❑ OR1ER❑ <br /> FACILITY FILE <br /> FAIR-t1Y ID# /1 J1/5��1p CRcss REFID# AaouNf ID# INm# 1,:30 <br /> liD�j <br /> L MA770N' <br /> is this a NEw Business LOGTION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES EX No ❑ <br /> is this an EXISTING Business LOCATION but a NEW T)W of regulated Business? YES ❑ No IN <br /> BhtsntLss/FAmIEr/sIEE NAHE Former Tiger Lines Yard <br /> SMADDRESS 1430 South Cherokee Lane SurE# Busr209) 334-4102 <br /> rR <br /> Cm Lodi STATE CA zip 95240 <br /> BOARDOFS1N9lw59RDurioncf WATION CODE IOYI WYZ <br /> Mailing Address YD09076Y AM fbciiityAddm" Attentlon:or Care OF(opOcivQ <br /> (Owner) P.O. Box 1120 Dennis Altnow or Don Altnow <br /> Mailing AddressCBy Lodi STATE CA ZIP 95241 <br /> sic cbm APN# Comm: <br /> THIRD PARTY BILLING INF.OI Complete if Billing Party is differentfrom Property Owner orFadlity Operator identified adom <br /> BusmEss NANE A/tentlon:wCare Of (op&&W) <br /> Nat Applicable - Bill Owner <br /> Mailing Address PING E <br /> CITY STATE 21P <br /> ar.-n.mi;n.,,aoame for fees and Charges OWNER FACILTfY/BUSINESS THIRD PARTY BILLING <br /> Hit IjNG AND COMET LANCE AYRNOW I FOf.MENT: 1,the undersigned Applicant,certify that I am the(Avner,Opemfer,or Anfheriaed Agent or this Business,and 1 ackno otedge that all P£RMrf nu, <br /> PPNA =,ENFlJRCEN£NTCHARWmml/or HODRLYCtTARGENassociated with thaoperation will be billed tame at the address identified above As the Acx=&TAnnRrxr for this site. Ialso certify,that <br /> all information provided on this application is our and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQmN COt Ordinance Coda and/or <br /> Sbndards and STATE.mllor FEDERAL Laws and Regulations As the undersigned owner,operator,or agent of the 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 DEPARTM NT ss soon as it u available and at the same time it is <br /> provided to me or my representative PI FCCF pRefr <br /> AwLIrANrNAME Dennis Altnow sIGNANRE <br /> TIRE Managing Co-Partner I°NNomtnlre tutnu�ND) <br /> Apposed By Date AcceuntinD Office precession Completed BY Doo it p 5 <br /> 29-02-002 April 25,2003 <br />