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. r . San Joaquin County Environmental Health Department DATE (� '� MASTER FILE RECORD INFORMATION "MFR" GREEN FORM 1".ncn encec Fn9 Eun NAF nNi v OWNER ID# CASE At UNIT IV OWNER FILE COMPLETE TMEFOLLOWING PROPERTY OWNER INFORMATION; CHECIKrF OWNER CORRENrtroNFnEwrrH EHD ❑ PROPERTY OWNER NAME Po(� o 5 t-oc, --"o(1 PHONE 20a - a 4 6- a 2 ti CG First L MI Last (� BUSINESS NAME TortL of Stocklo-n SOC SEC/TAx ID#lj/`' _&()CI q03 Owner Home Address 2201 W WCL s h 1 n I O Y� S}re e—� DRIVER'S LICENSE# `I I city 5�c cK�otn STATE CA g 5 2 0 3 Owner Mailing Address P.0 Box 20S2 q Mailing Address City 5 f o c k-I on U State CA ZiP 352-0 i TVDF nF nwNFDCNTD CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER FACILITY FILE FACILTr ID AtIf bo I 3� CROSS REF ID# [ACCOUID At (�O� 3 Lk-7 C INV# -I L� 3 L�Lk Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No )� BUSINESS/FACILITY/SITE NAME ?Q Yc e 112 we-5tc-omplex SITE ADDRESS Hoo e c -D n v e a� SUITE# BUSINESS PHONE CITY 5{ o c k SYATE CA ZIP q520-5 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYS KEY2 Mailing Address dDIFFERENTfrom Facility Address Attention:or Care Of(optional) P,0 , BGA 208cl R1�0, Koeh ner l Mailing Address City 5�o / �cI6 l M/� STATE ZIP 11 5 2C I SIC CODE APN# `J 1` COMMENTT THIRD PARTY BILLING INFO: Completed Billing Party is different from Property Owner or Facility Operator identified above. BUSINESS NAME Attention:orCare Of (optional) Mailing Address PHONE CITY STATE Zm 4ccou"4u.ncccc for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING $ILI JNt:AN C'nntPt.taNr`F ArtcNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the O ester,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERMn'FEEs, PENALTIES,ENFORCEMENTCHARGES and/or//OURLY CHARGES associated with this operation will be billed to me at the address identified above as the ArcouAT Anneecc for this site. I also certify that all information provided on this application is true and correct;and that all regulated activities"ill be performed in accordance with all applicable SAN JOAQIIIN COUNTN 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 above facility/site address,1 hereby authorize the release of 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 timc it is provided to me or my representative, f,, I /�C \ APPLICANTNAME JeF�rev VV II��t\ ( QtP�� SIGNATURE !�\J TITLE DRIC to v 11-© �Q n I( I m r I o- r ocov REOTnRED) L/ &q (�9 / 9 9 =App—,d I Date Accounting Office Processing Completed By Date \ �j 29-02-002 April 25,2003