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ff oun f ealt a rrI Environeariff DlvislonI <br /> DATE �1'� d I MASTER FILE RECORD INFORMATIO FORM (EHDDtS(REvmED07123197) <br /> SHADED AREA!FOR EHD WE ONLY -�: UNIT IV <br /> !OWNER FILE <br /> 'l <br /> COMPLETETNEFOLLOW/NG BUSINESS OWNER INFORMATION: CHECK/F OWNER CURRENTLYONFxEwt NERD <br /> N - <br /> BUSINESS Nancee Volpi <br /> PHONE 209 952-3194 <br /> OWNER NAME ----- --- --------------------` <br /> ..................................._...............................fiat..............................._.......W......_...............».....................LA7t..._......._...._.........._...... <br /> BUSINESS NAME(rf different from Owner Name) SOC SEC I TAx ID# <br /> OWNER HOME SS Annondale Drive DRIVER'S LICENSE <br /> city Stockton STATE Ca zip 95209 <br /> OWNER MAILING ADDRESS (ifDIFFERENTfrom Owner Address) Attention:orCare of (optional) <br /> Mailing Address Ci po box 58 _Steektel�- Holt : State Ca zip 95234 <br /> (nor.n O 5 O <br /> CORPORATION qy INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FAcruTYID# y`. � Pi' ^aCR033REFIVV '.!> ..rt "�,�.�ar� >� CCOUN'C `amu L ::.+aJ�._• -w� <br /> COMPLETE THEFOLLOWING BUSINESS/FACILITY I SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ Nox❑ <br /> Is this an ExIsnNG Business LOCATION but a NEW TYPE of regulated Business? V�` d Y S w f r YES ❑ No Cj <br /> BUSINESS/FACILITYISITENAME 14210 west Highway Four - Former Volpi Farms <br /> SITE ADDRESS 14210 West Highway Four SUITE# BUSINESS PHONE <br /> 209 4640508 <br /> CITY Stockton STATECA zip 95234 <br /> ...,.�«; �»"}.'z r r .:'iii ' '.e�•':r, .;..3'>-"'A-: .xA xy�;3-�'Rr,3, r+q�..'"5. -tw.. dr .,..L" Y4' `'i'Y;' '.::,d�'„ x <br /> Mailing Address ifDIFFERENTfrom Facility Address Attention:or Care Of(optional) <br /> Nancee Volpi <br /> Mailing Address City STATE zip <br /> *#,'40� ���'`'�, �iwt'"' �'".,�;sj�� a���•"�-�.*�,°.c'n�. .. -Iq'"'. <br /> .,n <br /> :APNi .„.r.''If-MZ'" :WIT <br /> THIRD PARTY BILLINGFORMATION: Complete if Billing Party is different from Business Owner Identifiedabove. <br /> Bu E dvanced GeoEnvironmental - Stockton Attention:orcareOf (optional) <br /> Bill Little <br /> Mailing Address 4005 North Wilson Way ` PHONE 209 467-1006 <br /> clr Stockton STATE Ca zip 95205 <br /> AccouNrADDREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all <br /> PERMIT FEES,PENALTIES,ENFDRCEMENT CHARGES and/or HOURLYCHARGES associated with this operation will be billed to me at the address identified above as the ACCo )yTADDRM <br /> for this site. I also certify that all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN <br /> JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the <br /> above facility/site address, I hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME �( � �( SIGNATURE <br /> `IF( 606413 .t <br /> TITLE DRIVER'S LICENSE# <br /> IPNOToroPv RFornaFn) <br /> nce Process li <br />