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03/21/2002 16:28 2094671118 AGE STOCKTON {n' PAGE 02 <br /> F� SI 'I HIS i; '..i�{';�� r <br /> GREEN Ft7RM <br /> DATE MASTER FILE RECORD INFORMATION 'kMFR'r <br /> 5WAP5P.9 -eo�r <br /> .6Ew AZstiou <br /> 151� UNIT IV_ P <br /> OWNER FILE <br /> - CHECKYF OWNER CURRfA+TtYONXt'12wfrxEHD ❑ <br /> COMPLETE THEr-vLLowjNGPROPERTY OWNER INFORMATION: <br /> PHONE <br /> taRIWERTY OwrItER <br /> NAMI! <br /> fFet tM <br /> Soc Sec/TAx ID# <br /> BustNEssNAML' fjA <br /> Owner dome Address DRrvnR's LicENSE# <br /> Ow <br /> 1 <e Kl nn t-t- ��N� <br /> CM'/ STDGK- STATE <br /> Owner Mailing Address <br /> $tate Zip <br /> Mailing Address City <br /> Type OF OWNEASta <br /> C6RPORATION❑ INDYvitDUAL AARTrttItSHrP C3 Fro AGENC/❑ OTHER C3 <br /> FACILITY FILE <br /> ..e _ !N <br /> C4MPL.ETETNEFOLLOWTNG BUSINESS J FACILITY tf SETE ZMFORMAMAI- <br /> Is this a New Business LocAnott not previously regulated by the ENvzRDNME14TAL RMTH OPPARYM MV Y ❑ No ❑ <br /> Is this an EnsTmG Business LocATION but a NEW TYPti of regulated Business 7 YES s [] No C:] <br /> BUSINESS/FACILITY/SITE NAME <br /> tJ � Sum#' BusTrIess PHONE <br /> Srl-EADouss ^w j TzJ� `.'x7, <br /> L <br /> cm / ' srat7� zip <br /> Mailing Address HDIFFFRENIfiamFacilityAddresy Attention:or Care Of{optlona!) <br /> l}"(� (o (tel►ub��- L�-!'C <br /> INailing Address Qty �����) STATE /)tn �P G,' C'7/1� <br /> 'THIRD PARTY BILLING INVO: COMPlete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> 13USINESSNAME n Attentlon:or Care Of (optfdnaV <br /> 1 v r' <br /> Mailing Address PHONE <br /> STATE IIP <br /> Crit <br /> COUKT.9D Fs for fees and charges Qt/y11ER FAC)UTY/BUSINESS THIRD PARTY 131LLWG <br /> i <br /> BILLING AND COMPLIANCE ACXNOWi$DCMENT: 1,the undersigned Appficant,ccrtifY that 1 am the Owner,Operator,or Authorized Agent of this Business,and I actmowledge tlwt all FLWIT F= <br /> prNALI7Es,ENrottezmLrPrr G,.1Rras and/or 80my C1LIRGES associated with this operation will be billed to meat the address identified above as the ACCOKWEADDRESS for this site. 111180 certify thnt <br /> all infornatien prodded on this applicafion is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIIt CouNTy Ordinance Codes and/or <br /> Standards and STATE and/or FEMRAL Laws And Regulations. Ax the undcrsigaed owner,operator,or arm*of the property located at the above facilityj$ite Address.I hereby authorize the release of <br /> any and oU results and environmental assessment information to SAN JOAQUIN COUNTY ENVIZONMENTAL REALTII DTFARTMTNT as soon as it is available and at the same time it s <br /> provided to me or my repr>zsentadva <br /> PLEASE PIUNT � <br /> APPLICANT NAME TQ.,p�j C.IS CO De-/-\r ji�- SIGNATURE <br /> TinE T V W n1(vim— y (PHO OCCOPY LICENSE <br />