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San Joaquin County Environmental Health uepartment <br /> GREEN FORM <br /> DATE y MASTER FILE RECORD INFORMATION "MFR" <br /> CHenFORFAs FoR FHn nCF nNl r OWNER ID# CASE# S I/ u 0 l X S <br /> n UNIT IV <br /> OWNER FILE O 1`– <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; CHECKrF OWNER CURREENTLYoNFILEWITH EHD <br /> PROPERTY OWNER NAME PHONE Z 10 – <br /> Z000 <br /> First MI Last <br /> BUSINESS NAME .tOSOC SEC/TAX ID# <br /> antro Ener Cor aCa� h VIA- Nod Re o-4f, <br /> Owner Home AddressDRIVER'S LICENSE# '�}r OI ~Lr L,Ohm Vedero Wa ✓A Y. <br /> Cih <br /> So-,^ A i,,%�oA I 0 STATE TX Z- 4 e Z � -16/6 <br /> Owner Mailing Address Po Box 6 1 6 0 0 0 <br /> Mailing Address City SOLA A-Yt�OA t p State TX zip <br /> 4 fi�/'G Q - b6'000 <br /> TURF QF nWNFRCHTR /, b ( <br /> CORPORATION INDrVIDUALE3 PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# 4O I CROSS REF ID# �L�W��-7 i ACCOUNT ID# Z 1 1 I INV# <br /> OMPLETETHEF LL OWING BUSINESS I FACILITY IWSrTE INFORMA7TON,' ✓(p `IY <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No CSI <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? n YES ❑ NO LJ <br /> BUSINESS/FAmrry/SITE NAME Voltrp <br /> SITE ADDRESS o C 2 G Nay ,v�lbr' SUITE# BUSINESS PHONE <br /> J vJ J slo- - v x � <br /> Clrr C c k V1 STATE CA ZIP A s'7 o 3 <br /> BOARD OF SUPERVIsoR DISTRICT LOCATION CODE KEY1 KEY2 ( L <br /> Mailing Address ifDIFFE NTfrom 1a,dl4yAlddress Attention:or Care Of(optional) <br /> 90 SO,-, ll /0 AVUuL RIC44 jkcwks SE M <br /> Mailing Address City Ciro ,44 STATECA <br /> ZIP q q 5--2 5—25— <br /> SIC CODE tw� APN# COMMENT: <br /> TARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> 00iPipsS NAME -�- Attent- of /national) <br /> Mailing Address //17 / ? _ P e /'i_ „ , PHor <br /> t CITY ' STATE/` /1 ZIP <br /> Y'a <br /> ACUAT 4DLPZSS for fees and charges ("/tel /.S <br /> OWNER FACILITY/BUSINESS THIRD PARTY BILLI--7 <br /> NG <br /> RD.i.t N'G AND('o Nf tANcF ',C2 <br /> *QA. LI1L1 L.",7. 1,the undersigned Applicant,certify that I am the 0—ser,Operator,ur Aulhori;ed A en1 of this Business,and I acknowledge that all PERAU7 FEES, <br /> PENALTIES,FNFURCEAILNT CINRGES and/or HUURL1"C1IAR6E4 associated with this(operation Hill be billed tome at the address identified above as the Accol'N-1 41)1)RL�x fur this site 1 also certift 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 C'OU,NT'Ordinance Codes and/or <br /> Standards and STATE and/or F EDF.RAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address.1 hereby authorize the release of <br /> — and all results and environmental assessment information to SAN JO.AQIRN COUNT) ENVIRONMENTAL HEALTH DEPARTNIENT as soon as it is available and at the same time it is <br /> provided to me or my representative. �J <br /> APPLICANT NAME t� PLEASE PRINT SIGNATURE C?� <br /> Vo�.ln Clark <br /> TITLE DRIVER'S LICENSE# '�Cs tr o Oq I <br /> To--,k M AcL S f a Geo o ,s� (PHOTOCOPY REOUMED) l <br /> Approved By .,� Datepr <br /> Accounting Office Processing Completed By Date <br /> 29-02-002 %pnl 25,200'' <br />