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San Joaquin County Environmental Health Department <br /> DATE July 2, 2010 MASTER FILE RECORD INFORMATION "MFR'S GREEN FORM <br /> SHADED AREAS FOR EHD USE ONLY OWNER IDX vi�l it-790 <br /> CASE# UNIT IV <br /> V LOWNER FILE <br /> COMPLETE THEFOLLOW/NGPROPERTY OWNER INFORMATION.' CHEcK1F OWNER CURRENTL YON FILE WITH EHD <br /> PROPERTY OWNER NAME MattSanders PHONE 540-966-5315 <br /> First MI JLast <br /> BUSINESS NAME Metalsa Soc SEC ITAx ID# <br /> Owner Home Address 1550 Industrial Drive DRnrER'sLICENSE# <br /> city Stockton sTATECA Zip 95206 <br /> Owner Mailing Address <br /> 1550 Industrial Drive <br /> Melling Address City Stockton state CA zip 95206 <br /> TYPE OF mERsHip <br /> CORPORATION® INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# 60,-1040 <br /> CROSS REF ID# ACCOUNTID# fl it INV# <br /> COMPLETE THEFoLLOW/NG BUST NESS/FACILITY/SITE INFORMATION' lXYYy/] <br /> IS this a NEW Business LOCATION not Previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ No <br /> IS this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No 29 <br /> BUSINESS/FACILfrY/SttENAME Metalsa <br /> SmEADDREss 1550 Industrial Drive SUITE BUSINESS PHONE <br /> CITY Stockton STATE CA z'p 90206 <br /> BOARD OF SUPERVISOR DISTRICT O LocATtoN CODE Q I KE11 KEY2 <br /> Mailing Address 1fD1FFERENrfrom Fac1A1yAddress / Attention:or Care Of(optional) <br /> Mailing Address City STATE zip <br /> ----]SIC CODE APN# / ', 29 0 S� COMMENT: <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner orFacility Operator identified above. <br /> BUSINESS NAME Attention:or Care Of(optlorml) <br /> ENVIRON International Corporation N m6k QxAe-Z0LdCk <br /> Mailing Address 707 Wilshire Boulevard, Suite 4950 PHONE 213-943-6300 <br /> CITY Los Angeles STATE CA zip 90017 <br /> ACCOUNTADDRESs for fees and charges OWNER FACILITYIBUSINESS HIRD PARTY BILLING <br /> BIELING AND COMPLIANCE AC'ICN01yLEDGNENI: 1,the undersigned Applicant,certiN-that I am the(hrner,(Operator,or Authorized A,gew of this Business, nd I ac Lnu%Icdge that all, 'RNTTi--FES, <br /> f'FAALTIES,E:vi*oi?(:E.HF.NTCYf.1R(,'E.S anti/or HOURLY 01ARGE.S associated With this operation will be billed to me at the address identified above as tile:tCCOUNTADDRF-.S.S for this site. I also certifv 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 COUNT%Ordinance Codes and/or <br /> Standards and STAT£.:Intl/or 6?al}.R.41.Laws nail Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> all)and all results and environmental assessment information to SAN JOAQUIN COUNTY ENN'IRON:NIENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME Alma Quezada PLEASE PRINT SIGNATURE/ "KV9—Q, <br /> TITLE DRIVER'S LI ENSE# <br /> Associate (PHOTOCOPY R A8490774 <br /> Approved BY !�1�— Date - -7 I b Acc(wntJnp Offlcs PrDcaaslnp Completed ay bb . c) <br /> 29-i12 IU;12101 MASTER 17ILF.RFC'ORn-GREEN <br /> CONFIDENTIAL <br />