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• -CHEVRON EMC 258420213 11/05 '0' :15 NO.523 02/03 <br />0 Q o012 0-3 OWNER FILE <br />COMPLETE THEFOLLOWINGPROPERTY OWNER INFORMATION.' CHEcKIF OWNER CURREIVTLYOIVFILEW77NEHD F <br />PROPERTY <br />OWNER NAME <br />Fti �.r,..' _ � I.z3'af.M:= r ?i rah P.r'-�i.E.., 'i4in. ;,, �114 � ! r•ca5'_ !"m' + <br />11 <br />rNaf <br />M! <br />THIRD PARTY BILLING INFO. Complete If Billing Party is diferentfromProperty Owner or Facility Operator Identified above. <br />PHONE <br />Mc&nas2rre.'r (fV4tpL1d')1 <br />roar <br />^j�y�� I(V,,t .3b0i4 <br />{}' <br />BUSINESS NAME D ' ` • <br />t <br />SOC SEC / TAX ID # <br />OWnor ome Address <br />City <br />UhZO� �QC�b��L �� �/ /J(j <br />Omvep's UceNSE# <br />STATE <br />LIP <br />Owner Making Addraaa <br />/q '3Ox <br />-776 _/ <br />Mailing Address City <br />3 v i oaN k_ <br />State CA <br />Zip 115,10 <br />COMPLEiL° iHEFOLLOWING BUSINESS / FACILITY / SITE INFORMATION.' <br />Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION ? YES (S?,' NO ❑ <br />Is this an ExIsTING Buainass LOCATION but a NEw TYPE of regulated Business ? YES ❑ No a <br />BUSINESS/FACILITY/SITE NAME, <br />�c� 1 <br />1A'0C_ <br />SREAoORESS SUITE# BUSINESS PHONE <br />�68�5 So:rEI� �i1aofiri-ltu/ l>ri�-- <br />CITU-7STATE <br />actCA ZIP <br />� <br />+��I�t�; li' LAN u� sxer< .I : _?� z+�ar � i��4�.,•a+itr , .—yR , �� �N a' �•esn;.,T.z �I.: n -, �i;�'r <br />;{_ <br />t4i7f ' R@IM � kiuE' .Scl ,, r x u ra '�, :I'• .i+Cl .si'-�'' it [C'.�li!E � it "ill i?�',`�i:T'i:�rljj <br />'• ''� +.J�E��JG4tl3Zit1<�lu^I <br />Maifmg Address tfDIFFERENTfrom FaeilltyAddress Attenton: or Care Of (optional) <br />Mailing Address City STATE Zip <br />L1J. , r ii •:....�4 ", iihmmr <br />Fti �.r,..' _ � I.z3'af.M:= r ?i rah P.r'-�i.E.., 'i4in. ;,, �114 � ! r•ca5'_ !"m' + <br />11 <br />' .r✓.• <br />•�=i <br />THIRD PARTY BILLING INFO. Complete If Billing Party is diferentfromProperty Owner or Facility Operator Identified above. <br />BUSINESS NAME GkeVtcan <br />Mc&nas2rre.'r (fV4tpL1d')1 <br />Attention: orCareOf (optional) <br />^j�y�� I(V,,t .3b0i4 <br />Mailing Address 'Y. 0, ick 60la Iz d0so I PHONE q of -rya- Isoy I' <br />CITYI g9S-� <br />a vl OtI'vI O to STATE �+ � LP <br />dmiy11i3ESY for fees and charges OWNER FACILrrY/BUSINESS THIRD PARTY BILLING <br />BILLING AND COMPUANCr. ACKNOWLEDGMENT: 1, the undersigned Applicant, certify that I am the Owner, operator, or Aurhor$ed Agent of thLs liusiness, and 1 acknowledge that all <br />P£RMITF£Ps, PF AL77m F_NFoRcj wrNTCHARGEN and/or HnUal.YCKARGE.T associated with this operation will be hilted to me at the address identified above as the ACCYIL'NTADDArss <br />lar this site. 1 also certify that all information provided on this application is true and correct; and that all regulate[ activities will be performed in accnrdance with all appiicahle SAN <br />tOAQVIN Couwry Ordinance Codes and/or Standards and STATE and/or FBnr.RAL "wt and Regulations. As the undersigned owner, operator, or agent of the property located at the <br />tbove fadlity/site address, I hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMEN'T'AL <br />4FALTH DIVISION as soon as it Is available and at the same time it Is provided to me or my representative. <br />// PLE/A3E PRINT <br />APPLICANT NAME /#1 5��� Q�S[ t I? SIGNATURE 8;,U ` y JU,,,j <br />r / DRIVER'S LICENSE 0 <br />TITLE J�ior ti~v rolnrvcvl l %fol�L-� sPcdcdfSt <br />6UNFIDENTIRL <br />