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055/2002 14:51 2094683433 FIFTH FLOOR PAGE 03 <br /> MW <br /> C <br /> FORM (EH001SIRE%13ED06J11/9T) <br /> DATE MASTER FILE RECORD INFORMATION <br /> UNIT IV <br /> OWNER FILE IAIcH-ccxtF OWNER CuRRENT4,roNFiLE wiTHEI-10 <br /> COMPLETErHEFOLLOWG BUSINESS OWNER INFORMATION: <br /> ...........I.........................................................................................1...................................... ...................................................................................................................................... <br /> BUSINESS <br /> STOCKTON PORT DISTRICT PHONE <br /> 209-946-0246 <br /> OwmEn NAME -------------------------- ---- --- <br /> mi ............ <br /> .................................. .......................... <br /> .................................................................... ................. ........................... <br /> BUSINESS NAME(If different ftm owner Name) SOC SEC ITP <br /> OWNER HajwE ADORES3 2201 WEST WASHINGTON STREET DMvER'S LICENSE NI <br /> STOCKTON STATE CA zip 95203. <br /> OWNER MAil-INGADDRESS (If CIFFERENT'fi-am Owrer Address) Attention:or-Cam of (optional) <br /> Msifing Addro----j City POST OFICE BOX 2089 STOCKTON Stal- CA ZiP95201-2089 <br /> CORPORATION 0 INDIVIOUAL 0 PARTNER5HIP 0 LOCALAGENCYO COUNTY AGENCY❑ STATE AceNcy 0 Fee AcENcy C OTHER tX <br /> FACILITY FILE <br /> w <br /> 0 0� <br /> W-'E ==011,1�W, x <br /> Z112 <br /> Cowl-=THE FouowlNG BUSINESS I FACILITY I SITE INFcRmArlow <br /> Is this a NEW 8u3ine-3s LOCATION not prcvioumly regulated by the ENVIRONMENTAL HEALTH Divistom YES Cl No 13 <br /> I.-thl3anEXISTING Business LOCATION but a NEW TYPE of regulated Eu3incz3 1 YES ❑ No <br /> ❑ <br /> 8u,.iNrzss/FAaUT`r1SITE NAMC STOCKTON PORT DISTRICT <br /> S91 <br /> SITE AOORr;SS HOUSE ROAD, ROBERTS ISLAND SUITE IT ' 9-0246 <br /> CITY <br /> STOCKTON STATE i ZIP <br /> CA y.95203 <br /> 4 ' <br /> Mailing Address if DIFFERENT from Facility Addrv= Attention:or Care Of(OP60nal) <br /> POST OFFICE BOX 2089 <br /> Mailing AddressC.ty STOCKTON STAT EtA Z'p 95201-2089 7 <br /> ? - N <br /> tie ft <br /> THIRD PARTY BILL]Nr. IrAFoFtmAmm: Complete if Billing Party is different from Business Owner Identified above. <br /> ................................................................................................................................................................................... .....................................--............................................................. <br /> BUSINESS NAMEAttention:Or Care Of iloio6orwl) <br /> GEOMATRIX CONSULTANTS, INC. PHILIP ROSS <br /> Mailing Address 2444 MAIN STREET, SUITE 215 PHONE 559-264-2535 <br /> CITYFRESNO STATE CA Zp 93721 <br /> Aj=Q1Z8G1ADDBZSS for fees and charges OWNER FAciuTyiEUSINESS THIRD PARTY BILLING <br /> 1310 mS:AND COmujA,4c.F,AC-3C4OwLEDGNI 1,the undersigned AppliVML.Cerllfp 11139 1 am the Omer.Operator,or elzahori:ed Agent of this Business.and I adma-ledge that all <br /> Per„ nzes. PrML= &-7oRcz.%ar--r CnAA=and/or ffoaU y CRARGES associated with this operation will be billed to me at the 2ddrL--% identified above as theACCou.%7' <br /> ADDRE for this site. 1 3130 ccrtiry that all information provided on this Application is true and correct, and that all rc-.ulntvd act;,vitjj!s will be performed in accordance Nith all <br /> applicable SAx JoAQurq CaV.,nN Ord inaacc Codes 2nd/or Standards and$TATE and/or FEDEPAL Laws and Regulations. As the undersigned owner.operator,or 2-,cnt of the pro perry <br /> located at the above facility/site addrcLc. I hereby authorize the release of any and all results ;%nJ environmental -'Mws;% nlorma QUIN COUNTY <br /> HEALTH DIVISION as soon as it is available and at the same time it is provided to me of my repircientat" <br /> PLEASE PRINT <br /> APPLICANT NAME PHILIP ROSS SIGNATURE <br /> TITLESENIOR HYDROGEOLOGIST—GEOMATRIX CONSULTANTS DRIVER'S LICENSE 151: <br /> APprobst�`Ry�v <br /> 7 5 <br />