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0,4/19/07 13:01 FAX 618 281 7020 PHILIP SERVICES U002 <br /> San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DAIS MASTER FILE RECORD INFORMAnON "MFR" <br /> Gins ipD aaoac Toa FMn ncc nnv OWNER ID# GSE# UNIT IV <br /> 0l,)oo\Sob. <br /> OWNER PILE <br /> ComPLE7E rHE,FwowjN4GPR PERTY OWNER INFO mUom OtcarrF OWNER LT/RRENrzyoNFnlEtt?Tr/EHD ❑ <br /> PROPERTY OWNER NAME Edward Overton PHONE (209) 951-8409 <br /> First Ml Last <br /> BUSINESS NAME SOC SEC/TAX ID# <br /> Owner Home Address 1320 South Van Buren Street Darvat'sumuE# <br /> sty Stockton STATE CA ZIP 95206 <br /> Owner Mailing Address Same As Above <br /> Mailing Address City State Zip <br /> IYRP nc fha ono <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ Fen AGUJCY❑ OTHER❑ <br /> FACILITY PILE <br /> FACIIJTY ID# CROs RIF ID#( AccoUNT ID#oul�3i4 QP10529os� 312 � S�Z <br /> Is this a NEW Business LOCATION not previously regulated by the ENvIRoNMENIAL HEALTH DEPARTMENT? Pts ❑ No <br /> Is this an EXLIMNG Business LOCATION but a NEW TYPE of regulated Business? PEs ❑ No ■ <br /> BUSINE.ss/FAm.r"t/SITE NAPE Former Columbo / Toscana Bakery <br /> SrMADORM 1444 South Lincoln Street SUITE# Bt N1ESSPHOE <br /> CITY Stockton STATE CA im 95206 <br /> BAWD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Add raw ifDIfFFRENrrtvm FadWyAddress Attention:or Care Of(aptiorW) <br /> Mailing Address City STATE ZIP <br /> SIC CODE 11 AM* COMMaer. <br /> THIPM Pwnrtf BILlONG INFO: Complete if Billing Party is&Ferentfmm Property Owner or Facility Operator/denbfied above. <br /> BuMPNW NAME AttBltioir OrCare Of ( /J <br /> PSC Environmental Services Paul Anderson <br /> FZ-7-9-Ld-- <br /> 210 West Sand Bank Road PHONE <br /> (6I8) 281-1543 <br /> CnT Columbia STATE IL ZIP 62236 <br /> AcoxamADaew for fees and charges OWNER FACILi y/BUSINESS ITHUM PARTY BIWNG <br /> Hit : I,the undersigned Applicant,certify that I am the Oreo.Operator,or Authorized Agent of Ibis Business,and I acknowledge that all PEKWTFEES, <br /> PENALnEv,BNFORCEafENT CTIARGFS and/or HOURLY CFTARGFS associated with this operation will be billed tome at the address identified above As the ArMUNTAnORFeg for thie aile.I also certify that <br /> CII information provided an 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 FsDSRAL haws and Regulations. Aa the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQLTN COUNTY ENVIRON34ENTAL FWALTH DEPARTMENT as soon as it is available and at the acme time it is <br /> provided to me or my representative. <br /> APPLICANT NAME Paul Anderson PLEASE PRINT SIGNATURE <br /> TITLE DRIVER'S LICENSE# <br /> Authorized Agent For ILP tPHarocopyREoumEDI <br /> Approved By Date Accounting Offlce Procesdng Como~sY (T Dae& <br /> 29-02-002 April 25,2003 <br />