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San JCounty Environmental Health I,epartment <br /> GREEN FORM <br /> DATE 03/10/05 MASTER FILE RECORD INFORMATION "MFR" <br /> cw. rmrunh,ccnnr OWNER ID# CASE# UNIT IV <br /> OYYNER FILE <br /> COMPLETE THEFOLLOWI/YG PROPERTY OWNER INFORMATION; agx:;rze OWNER CUMENHrMMEI0WA(END <br /> "10PE1TTOYRIE`NME ILTS Rentals LLC I PH (209) 334-4102 <br /> First MI Last <br /> BtrmfF�Nara <br /> LTS Rentals, LLC Soo SEC/T"M#— <br /> Owner Hume Addles 927 Black Diamond Way DaIVER'sLToatie# <br /> CAr Lodi STATE CA 95241 <br /> Darter Mailing Addrhs <br /> P .O. Box 1120 <br /> Mailing Address CRY Lodi SCCA LP 95241 <br /> ,..aa nr„w»ro�ne <br /> C.oatoBATmR 00 Irrolvmuak❑ PARTrQ:ASHIP❑ FtDAGFNCY❑ OrREn❑ <br /> FACILITY FILE <br /> FA[Rm ID# CR055REFID# A=Ww IO# INV# <br /> irpmPLE7F7HEFouowDyc BUSINESS I FACILITY I SITE rNFORMATION.- <br /> Is this a NEw Business LOGTwN not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES EX No ❑ <br /> Is this an EnsTDIG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> Busa�ss/FAhanTJSITE NAME Former Tiger Lines Yard <br /> SREADd1E55 StrfTE# Btf <br /> 1430 South Cherokee Lane (209) 4-4102 <br /> aTY Lodi STATE C A W <br /> 95240 <br /> Boanoor$UPfRVLSOnDmtwr LOCATM CODEKEY, <br /> KE-2 <br /> Mailing Address dFDL7BWVr1hvm FanWAIditress Attention:or Care Of(ophand) <br /> (Owner) P .O. Box 1120 Dennis Altnow or Don Altnow <br /> Mailing Address City Lodi STATE CA zm 95241 <br /> Sic CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete/f 81111ng Fatty is different from Property Owner or Facility Operator idenbfic-d above. <br /> BIJSDIMNAME Attention:OrCam Of (OPbiOal) <br /> Not Applicable - Bill Owner <br /> Mailing Addles Not <br /> Cm STATE 21P <br /> wammizwr,woas for fees and Charges OWNER FACILNYBUSINESS THIRD PARTY BILLING <br /> R11j,MG AND f IIIrl Nfr`C"Ovn rnr:MENT: L die undersigned Appiirant,certify that I..the Oaver,OpeMM,or Awhonrvd Agan of this Business and I acknowledge that all F£ M fEE.S, <br /> PENALTTFS,ENPoACEMEMGIAAGEe and/or HODRLYCHARGES associated with this operation will be billed tow at the address identified above as the ACCDONPADDREM for this site. I also certify that <br /> all information provided on this application is true and curreey and that all regulated activities will be performed in accordance with all applicable SAN JOAQMN CotmY Ordinance Codes and/or <br /> Standards and STATE ahid/or FEDERAL Laws and Regulations As the undersigned owner,operator,or agent of the property located at die above facility/site address,l hereby authorize the release,of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART NT as soon as it is available and at the same time it is <br /> provided to me or my representative �"nt r <br /> APPLICANT NAME Dennis Altnow PIEASE Papfr 11UNIFlDEl'P1 NE <br /> TITLE Managing Co-Partner DRIVrTocorTILICENSE <br /> (PMSEo) <br /> Approved By papa A¢ohhndhg Otfur Proressing Completed BY Data <br /> 29-02-002 April 25,2003 <br />