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10/25/99 TION 13: 18 FAX 209 948 0621 KLEINTELDER INC 2002 <br /> DATEq GREEN FORM <br /> E" Z.5 1 I MASTER FILE RECORD INFORMATION "MW" <br /> �H4REQ�AEAs Fyq HD Ue�O� �1 '� , UNIT IV <br /> OWNER FILE <br /> :OMPLETETNEFOLLOW/NG PROPERTY OWNER INFORMATION,- CHFCKIF OWNER CURRENTCYpNFILE W/THEN <br /> PROPERTY <br /> PHONE <br /> OWNER NAME <br /> FI71 Ar <br /> 3V81NE99 NAME O "SFC T�ID p <br /> Jwner Home Address OCT Z '7ER's LICENSE a <br /> ;Ity <br /> .STA�ET�j ZIP <br /> lwner Malling Address L/ <br /> ��5 /7 2ap2 � PERMIT ! SERVICES <br /> till-9 Address City �G LSlate ev �Z' <br /> YPF OF QWNFRAWIP // /J <br /> :ORPORATION❑ INDIVIDUAL Cl PARTNERSHIP❑ _ _ FED AGENCY❑ OTHER❑ <br /> +���7I,I�jg�R��ppgg�� FACILITY FILE <br /> 1:I1: � ME � if�£411 MYA uwAb tt;.'�`, '..",LL�t - I�vx ' . <br /> OMPLETE rHEFOLLOW/NG BUSINESS/ FACILITY/SITE /NFORMAnON: <br /> I this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES N <br /> I this an ExiSTINO Business LoC.ATIoN but a NEW TYPE of regulated Business 7 YES ❑ NZ� <br /> U91NEa9/FACIUIYI5ITE NAME <br /> ITE AOORESS r1 <br /> / m o /[11, SUITE NBUSINESS PHONE <br /> (1 ) I <br /> STATE ZIP O 3 j <br /> r.�- <br /> ailing Address l(DIFFERENTfrom FeeriltyAddress Attention:or Care Of(optional) <br /> alling Address City --- <br /> STATE ZIP <br /> IRD PARTY BILLING INFO: Complete/f Billing Party is different from Property Owner or Facility Operator identified above. <br /> )SINE9s NAME Attention: or Care Of (optional) <br /> ailing Address P 6,y Z 62- <br /> Z PHONE <br /> TY ff VC5 VV 0A 1 STATE <br /> ^�f011e(LBDpRESs for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> .ING AND COMPLfANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that(Fit"the Owner,Operator,nr Antrrnrhed.lRent of this Ituvine.cv,And 1 nclknnwlvilgc thiel All <br /> drTFEES,PENALTIES,ENFORCEAIENTCIIARGETand/orHOURLYCl/ARGF_SaseoelAled with this opers thin will be billed Io me At Ibe addrecs identified Ahove As the AccofwrADPRECS <br /> Nis she. I also cerllry that All Information provided nn this Application is true and correct;And IhAI all regulAled A[Iivilles will he performed In ACCOrdanee With All Applicable SAN <br /> IUIN COUNTY Ordinance Codes And/or Standards and STATE And/or FEDERAL LAWS And Regulations. As the underllRned owner,operator,or agent of the property localcd Ill the <br /> e fncfllty/site address, 1 hereby authorize the release of any and all results and environmental Assessment Information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> LTH DIVISION as soon as It Is available and at the some time It Is provided to me or my representalive <br /> PLEASE PRINT r <br /> PLICANT NAME t ,C GQ/� SIGNATUR <br /> rLE Py--e We Ll, DRIVER'S Lp O � — 7 <br /> c fPHr1Tn OPY RE RF Ol11RGn1 <br /> t ig� " ;;+ J� &i]nUn Clffide�f f7o6seln�j G`olnpleteid "� <br /> Date <br />