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San Juin County Environmental Health 0artment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> SHADEDAREAe FOREHOUMONLY OWNERID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NG PROPERTY OWNER INFORMA T/ON.' CH£ar/r OWNER cuaxENnyoNNt mszH EHDEl <br /> PROPEMONNERNAME Leprino Foods Company PHONE <br /> First MI Last <br /> BUSINEWNAME LEPRINO FOODS COMPANY SDOSecITAXID#NA <br /> Curtner Home Address DRIVPa's LICENSE#NA <br /> City STATE zip <br /> owner Melling Addre0e2401 NORTH MACARTHUR DRIVE <br /> Mailing Address City Stam CA ZIP95376 <br /> Tracy <br /> TyproFOwNeggrup <br /> CORPORATION® INDIVIDUAL[:1 PARTNERSHIP❑ Fw AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FAc1un ID# CRoss REFID# AccouNrlD# 3/ f INV( <br /> U / <br /> COMPLETE THE FOLLOW/NG BSINESSFACILITY/SITE INFORMAT/ON.' {ob <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 NEIN TYPE of regulated Business? YES ❑ No <br /> BUSINE99IFACILm/SrrENAME Leprino Foods Company <br /> S-ADUREen 2401 North MacArthur Drive, SurrE# BUSINESS PHONE <br /> cm Tracy, STATE CA ZIP95376 <br /> BDAROOf SUPERVISOR DISTRICT LOCATRJNCODE Kart KEY2 <br /> Mailing Address dD/FFERENTimert Fac//Hy Address Attention:or Care Of(opLonaQ <br /> Mailing Address City STATE ZIP <br /> SICCODE APN# COMMFM: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> Busn ess NAMEGeoTrans, Inc Atmntlon:orCare Of(optY.#13rent an Shine <br /> Mailing Address 363 Centennial Parkway,Suite 210 Louisville,CO 80027 PNONE <br /> Dire Louisville STATECO ZIP80027 <br /> 9GFpHA79Qpg W forfees and charges OWNER FACIUTYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACRNOw'LEDGMENT: L the undersigned AppGeanl,certify that 1 am the Owner,Operator,or Authorized Agesr of this Business,and I acknowledge that a6 Putman FEES, <br /> PENAL Tres,ENFORCEVENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the ACCOVWADDR£SS for this site. 1 also emtify that <br /> all Information provided on this application is true and cormer;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN CQUNEY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Lmvsand Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,l 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. <br /> APPLICANT NAME Brendan Shine PLEASE PRINT SIGNATURE <br /> TITLE Senior Engineer DRIVER'S LICENSE# <br /> (PHOTOCOPY REGUIRED) <br /> Appravatl By DeM Accounting Oake Processing Completed By Dere <br /> 29-002 April25,2003 <br />