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10/25/99 MON 13:18 FAX 209 948 0621 KLEINFELDER INC 2002 <br /> 7061-T_ft 6.�PUVI�c EfWIFf3f ffl 4ealth:Dii,isioli r w <br /> .DATE11 IoLZ5 MASTER FILE RECORD INFORMATION `'MFR" GREEN FORM <br /> 5 y <br /> 004REQZ9EsP Fs9-EHU UNIT IV <br /> Usl_Ogyy a y 41 <br /> r <br /> OWNER FILE <br /> COW=7UIFFOLLOW/NG PROPERTY OWNER /NFORMAT/ON; CH£CKIF OWNER CuRRENTLYoNF/LEW/rHEH <br /> PROPERTY <br /> PHONE <br /> OWNER NAME <br /> Fi�l 1111 <br /> aUBINFsB NAMENt— EIV TA IDM <br /> 41-77 AJ�tf L G 0(1h a I �C(Z\/,+1-10 2.. ...,, <br /> Owner Home Address <br /> OCT 2 7MER's LICENSE# <br /> �i� ZIP <br /> Ownor Ma11TngAddreaa a1/ 2�Q � PERMIT / SERVICES <br /> alllnp Address City <br /> _ZVPF r1F nrmFOQMIP — <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERBHIP❑ FED AGENCY O OTHER❑ <br /> FACILITY NAMFISOMMININIMMINILE y <br /> ' �r''n' �"'.eM�U�JT�b N 1`t <br /> COMPLETE rHEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION. <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ N <br /> Is this an EXisTINO Business LOCATION but a NEW TYPE of regulated Business? YES C] N <br /> BUSINEBs/FACILfTY/SITE NAME <br /> 0Ar7-/ti G,lrA-L GQ,4-, rGzyf-7� <br /> SITEAooRE9S <br /> le U dL JK , SU17E# BUSINESS PHONE <br /> I <br /> CITY /a� STATE ZIP2 O 3 <br /> S?vc��v l/(f �, 2 <br /> .. .. - .✓i.. • , .. Z r ,.a r.7 <br /> Kan <br /> 1.7 <br /> Mailing Address IFDIFFERENTfrom Fecl/llyAddrsse Attention.or Care Of(opliona/) <br /> Melling Address City STATE ZIP <br /> 191211 <br /> w <br /> erent from Property Owner orFacility Operator identified above. <br /> HIRD PARTY BILLING INFO: Complete if Billing Patty is diff <br /> BUSINESS NAME t r1 Attentlon: orCare Of (optlona/) <br /> - k11t1i1kJ1 4, <br /> Mailing Address P. G box 6Zq 10PHONE ` <br /> /-551- <br /> CITY <br /> VC-5 rto /a- STATE S IP <br /> p <br /> s ouNrAgffl ,q for fees and charges OWNER n FAdLI7/Bh16IN4S3 THIRD PARTY BILLING <br /> LLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Appllcanl;cerflty IA.I 1 am the Owner,flpernlnr,or ADllrnrizeAAXenI of this lluvineSs,and i acknowleJl;c Thal ail <br /> 'RMITFEEv,PENALTIES,ENFoRCEMENrC21RaEcand/or H0UR1.YCNARGF.Sassocfaled with this operFillon will he billed to are at the address idcntlried above as the ALY--OURTADDRESS <br /> -this site. 1 also cerllry that all Information provided on this applicaiton Is tnfe and correct;Find that all regulated nolvllles will he pertarnled In accorfhlnce will'all applicable SAN <br /> AQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL.Laws and Regulations. As the undersigned owner,operator,or agent or the property located at The <br /> uve facility/slle address, 1 hereby authorize the release of any and all results and environmental assessment Information to SAN JOAQUIN COUNT-Y ENVIRONIIIENTAL <br /> sALTH DIVISION as soon as It Is available and at the same time it is provided to me or in),representative <br /> PLEASE PRINT r <br /> MPLICANT NAME I }Cr)lr 71-1 SIGNATUR <br /> 'TYLE 'Z— DRIVER'S LICEN #- Z/ 7L <br /> till : <br /> af3trt'11 rUA$iLfi�ln"t',�ide I�Ft�nats8ltb <br />