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03:21/2002 16:28 2094671.118 AGE STOCKTON PAGE 02 <br /> lam <br /> I - <br /> 1, 1 , <br /> I a nu i i..... i <br /> DATE MASTER FILE RECORD INFORMATION '%"MIFR" GREEN FORM <br /> SwAP5R.9PEAimnEHnusrQ&v �Cq�2 ,f UNIT <br /> NIT IV <br /> J OWNER FILE <br /> COMPLETETHEFOLLowiNGPROPERTY OWNER INFORMA7TON: C/YEeffY# OWNER CURRavnycjv xwwzmFHD El <br /> PROPERTYOWNI;R {,� �+ � PHONE <br /> U <br /> NAMis 1 �7V 1__.t Oreo <br /> fleet M! lest <br /> BUSINESS NAME N ASOe Sec/TAX IJa# <br /> , <br /> Owner Home Address ' DRIvER's LicENse# <br /> 1 lJl t`� <br /> ' City S�G1G�QriJ t��— STATE�� ZsPQ �Zt�tp <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> TYPe OF OWNERSHIP <br /> CORPORATION L'7 INDMDUAL PARTWgRSHrP❑ Feto AGENCY❑ OTHER❑ <br /> 3 g FACILITY FILE 2-3 <br /> CONIPL-FTETHEFOLLOWTNG BUSINESS f FACILITY f SITE 1'NFORMA770N. <br /> Is this a NEw Business LOCATIoN not previously regulated by the EmmommefrAt,ttF,ALTH OEPARTMEIM YES ❑ No ❑ <br /> is this an EXESTING Business LocmoN but ayNEw TTypipis of/regulated Business? YES ❑ No ❑ <br /> Iausrm Ess/FAciuTv/SITE NAME <br /> SrrEADDRESs Sum# Bustriess PHorie <br /> crry STATE A— <br /> ZIP <br /> Mailing Address YDIFFERENT from Facility Address Attention:or Care Of(optional) <br /> 4A-l 4k L JAI►nA*kt-_ L. <br /> Mailing Address Clty STATE 04—Pp 'rf S70(, <br /> Kik <br /> THIRD PARTY 13ILLING IN1t:O_ Complete if Billing Party is different from Property Owner or Facility Operator idendf/edabove. <br /> BUSIMSSNAME Attention:or Care Of (opflenaq <br /> NA— <br /> Mailing Address PHONE <br /> Crry STATE Zip <br /> ��1{ qvt for fees and charges OWNER FACMITY11BUSINESS TwIRD PARTY StLLwG <br /> I�IIIa G9�I I II I Ileal lel � <br /> BILLING AND COMPLIANCE ACKNOWLBoCMENT: I,the under3igned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PLWIT FEZS <br /> PeNALtlts,ENlORCFhfENT CFfi1Rr,Cs and/or I10f1RLYCtTARGFs associated with this operation will be billed to me at the address identified above as die AccomTALDRFss for this site, i also certify that <br /> all information provided on this application is true and correct:and that all regulated activides will be performed in accordance with all applicable SAN JOAQulm COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or itDERAL Laws and Regul'ationt. As the undersigned owner,pperator,or agent of the Property located at the above facilityisite address.J hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH J)1FrARTMENT as soon as it is available and at the same timte it is <br /> provided to we or my representative. <br /> PLEASE PitiNr <br /> APPLICANT NAME -reaMj(2,L4,C L)C_ ^\71JV1A- SIGNATURE <br /> Q� <br /> TALE ri a,[�..–.., n w j�,` DRIVER'S LICENSE <br /> P'�Vi 1�' (PHOTOCOPYARQUIREo) <br /> AN -1- iiiear s :�`= t I. - ,l 'rmom <br />