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s <br /> San Joaquin County Environmental Health DeNa'rtment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# F <br /> CASE# UNIT IV <br /> OVMER FILE <br /> COMPLETE THEFOLLOwING PROPERTY OWNER INFORMATION. CHECK/F OWNER CURRENTL roNFILE wiTH EHD <br /> PROPERTY OWNER NAME PHONE <br /> '1 First MI Last <br /> BUSINESS NAME ( {- '✓ r'� .,p s SOC SEC I TAX IO# <br /> Owner Home Address 1 �1 (Sa x I���I////�����'"' 6666 ` JY� DRIVER'S LICENSE# <br /> City STATE CIA— ZIP / .� a­ <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF 10# ACCOUNT IO# INV# <br /> COMPLETE THEFOLLOw/NG BUSINESS/FACILITY/SITE INFORMATION.' <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ No E3 <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No [?T <br /> BUSINESSIFACILITYISITENAME WEST COAST TOMATO OF CALIFORNIA, L.P. <br /> SITE ADDRESS 2900 E. HARDING WAY SUITE# BugIN T)PIr i!F 4 54 5 <br /> CITY STOCKTON STATE CA Zip 95205 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address ifDIFFERENTfrom Facii/tyAddress P.O. BOX 936 Attention:or Care Of(options/) <br /> ROBERT SPENCER <br /> Mailing Address City PALMETTO STATE FL Zip 34220 <br /> SIC CODE =FPN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete dBilling Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME GROUND ZERO ANALYSIS, INC. Attention:orCare Of/opUol�al) <br /> GREGORY P. ST <br /> Mailing Address 1714 NIAIN ST. PHONE (209)838-9888 <br /> CITY ESCALON STATE CA Zip 95320 <br /> A_ecoudlADDREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authoriz d Agent of this Business,and 1 acknowledge that all PERM/T FEES, <br /> PEN U.11ES,ENGORc'EMEATCHARGE.S and/or HOURLYC'IIARGE-.1'associated with this operation will be billed to me it the address identified above as the ACCOUNTADDREJ'S for this site. 1 also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> NAME G j_C G SIGNATURE �L v � 14v— <br /> APPLICANT <br /> TITLE / G [��UN� LYS/S DRIVER'S LICENSE# ,. 13�� 04j <br /> V ' / (PHOTOCOPY REQUIRED) ►'V t� <br /> Approved By Date Accounting Office Processing Completed By Date h <br /> 29-02 10/12/07 MASTER PILE RECORD-GREEN <br />