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San Juin County Environmental Healthldpartment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> SHADEDARFASFOREHDuaEONLY OwNERID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NG PROPERTY OWNER INFORMATION: CHecx1R OWNER CuxaexrzroNRLewmt EHD <br /> PROPERrYOMNERNA us Leprino Foods Company PHONE <br /> First MI Last <br /> BU81NMNAME LEPRINO FOODS COMPANY Soc SEc/TAZID#NA <br /> Owner Home Address DRwEss LIDENsE#NA <br /> city STATE LP <br /> Owner Mellhp Addrese2401 NORTH MACARTHUR DRIVE <br /> Mailing Address City Stem CA ZiP95376 <br /> Tracy <br /> TYPEOFOWNFREHIP <br /> CORPORATION® INDIVIDUAL El PARTNERSHIP FED AGENCY❑ OTNER❑ <br /> FACILITY FILE <br /> FAcWTY ID# CRoss REF ID# AccoUNT ID# Its. <br /> COMPLETE THEFOLLOw/NG BUSINESS/FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BusiNEsaFAOlury/sITENAME Leprino Foods Company <br /> S-ADDREsa 2401 North MacArthur Drive, suing# MAIN PHONE <br /> Cm Tracy, STATE CA ZIP95376 <br /> BOARDOFSUPERVISORDI iC LocATION COOS KEY1 KEY2 <br /> Malting Add reaa IfCIFFERENThrrm FacnNg,Addrs" Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE AEN# COMMnar: <br /> THIRD PARTY BILLING INFO: Complete if Billing Pa is diKerent from Property Owner or Facility Operator identified above. <br /> BUVNESSNAME GeolTfanS, Inc -� FV �i CC f__A4enti.:rN'Cam Of(WeDW)Brendan Shine <br /> Mailing Address 363 Centennial Parkway,Suite 210 Louisville,CO 80027 Ct tAjC>Y'C Yo rp�-E? PHONE <br /> cm LouisvilleIns) ` sTATECO ZIP80027 <br /> Accofoyrollffi4 forfees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that 1 am the Owner,operator,or Authorized Agent of this Business,and I acknowledge that an PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above As the AccouvrAooaess for this site. 1 also unify that <br /> all information provided on this application is true and carrecG 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,I 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. i <br /> Brendan Shine PLEASE PRINT SIGNATURE <br /> APPLICANT NAME B <br /> TITLE Senior Engineer DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIRED) <br /> Approved By Osla Aacountlrg ORiee Proeesellq Completed By Dere <br /> 29-002 April 25,2003 <br />