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SAN JOAQUIN COUNTY . PUBLIC HEALTH SERVICES . ENVIRONMENTAL HEALTH DIVISION <br /> FORM {EH OO f 5(REVISED 10/02196) <br /> DATE 05/16/97 MASTERFILE RECORD INFORMATI� <br /> SH.4DED.SECTAOWFOR ENDUSE OI2Y ow�itDs 12 <br /> � CASE <br /> OWNER FILE �&*037177 <br /> COMPLETETHEFOLLOW/NG BUSINESS OWNER INFORMATION.- CHECK,F OWNER CURREAfnYON FILE WITH EHD <br /> ---------------- --- <br /> BUSINESS OWNER PHONE <br /> NAME <br /> BuslNEss NAME(If different from Owner Name) Soc SEc 1 TAx ID s <br /> ARCO products Company <br /> OwrAM HOME AooRESS ORrvER s UcE1SE t <br /> CZ hal nS,T <br /> CRY STATE = ZIP <br /> OWNER MAnjmGAooREss if0/FFEREVrfiVen OWnerAddraSS Attention:or Care of (op6ona/t <br /> 4 rpr)i n T)ri irp <br /> Mp <br /> Mailing Address C9ty <br /> state <br /> Ta Palma CA 0623-1066 <br /> TYPE of OwmStwo: <br /> CoRPoRATKm INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ Cou NTY AGENCY❑ STATE AGENCY❑ Fm AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY IU>T•. CROSS REF ID S ACCoufrl lD t/ <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: <br /> Is this a NEW Business Lo AT1oN or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DmslO 7 YES Xx No ❑ <br /> Is this an EnSTING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No ❑ <br /> Bustw-ssIFACQnY N^w(THIS wdL aE THE NAME oN HEALTH PERMIT) <br /> Aif/PM Facility ( proposed) <br /> FAcam AaoaEssirFACrurr/sA/Ios&EF000 UArroRF000 V6acxELAIECOGmssARYADORESs) = SunE! Bt8sFs5 PHowE <br /> 2470 West Grantline Road <br /> QTYJFFAcniTYSSAAaerteFoovtAeTorrFowVa cLELA9ECoMrssARYADoREssC;TY STATE Z8 <br /> Trac CA <br /> if3oiifnoF3tfe�iypdit]iszRcs > <:hciitioer:CooE ...:; KtTrf�. ... ;. " < .... '� <br /> MaiTuq Address f[frHeattb Hermit NDIFFERENrfrwn Facr7dyAddneaa Attention:or Cane Of(opboaaQ <br /> Mailing Address Cites STATE ZIP <br /> .. <br /> S1DL^aeE ' �„ APN; Cbsae[I� 3- <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above. <br /> reustmsa NATE Attention:orCars Of (optiom* <br /> SECOR In Incorporated Mr . Nadeem Srour <br /> MaAing Address PHONE <br /> 25864-F Business Center Dr . ( 909) 335-6116 <br /> IT -43 15 <br /> Y <br /> Redlands <br /> STATE CA :: 92374 <br /> ACCOUKrAQ36Ess for fees and charges SER ❑ FACIUTYBUSINESS ❑ THIRD PARTY BIWNG fk <br /> BILLING AND,CoNeLiANcF AcxNowLEDGMENT: L the undersigned Applicant, certify that I am the Owner, Operator, or Authorized <br /> Agars of this Business, and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HovRLI' CHARGES <br /> associated with this operation will be billed to me at the address identified above as the Accoum ADDRESS for this site. I also certify <br /> that all information provided on this application is true and correct; and that all regulated activities will be performed in <br /> accordance with all applicable SAN JOAQULN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL, Laws and <br /> Regulations. <br /> PLEASE P <br /> APPLICANT NAME SIGNATURE <br /> Tedd J . Brown for Na S ta-1i I <br /> TITLE Staff Geologist (P�oTOCO"RECX m) B5781241 <br /> Aper erred 8y Date Accountir Office Processing Completed$y oats <br />