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San Joaquin County Environmental Health department <br /> DATEFMASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> G- 1 3 -�� SITE MmGATION&LOP <br /> GMM AMN MR 00 Uff 00M oertl::RIM cass0 UNIT IV <br /> Own RM z0ow m wEmuoWIw PROPERTY OIAIMER/NFv=AnoN OwexAr OWNER Czawwworrra smm END13 <br /> I'MMMYOVIMNAat Margaret Marci (201 522-4119 <br /> F&M AN Lauf P"oNs Nun= <br /> SUMM"NAna t:-aArlAotne <br /> N/A N/A <br /> Owner Hone Addmee <br /> 20 Mobile Lane <br /> CRY STATE ZIP <br /> 5531 <br /> Cresent City CA <br /> Owm w 6 Wft Addrew <br /> same as above <br /> ftM"Address City SIB,, zo <br /> CORPORATION❑ TNM MA".❑ nw Asew❑ OMR❑ <br /> STAB Stl7NfMMM_ECTAL Assewma_VOURdTAW CWMW_WATBR QuAUTV_HW AM=11[AMSTlOAUM_LOP <br /> FAcmm lD O bM Aocotetr lD AWWROfn <br /> 3Lk1. Ia. <br /> FAPdUW F M CRmmm ThvFvLLowm BUSINESS/FACILITY/SITE Moate um. <br /> bUibeNEWBusbw=LocATwNnotprovknoly rag i b led by#w ENw TAL H3ALTH DEPART 0n? Yes ❑ No 0 <br /> b thb an Enswin Bushmess LwAnom but a NEE TVm of ragulated Buslnoss7 Yes ❑ NO 13 <br /> A3AFACRJTYISITtHAM N/A <br /> 2969 Loomis Road E1Nr40 ess t <br /> Crn Stockton &T1 2r 95205 <br /> 00NW0FeWWWa"0M"= LOCATMOM Kew :�=Z <br /> ft0 to A Umn A10*M JPEJVrdenr A Adio,naae AftenUm arCtwo Of(*Ftbr" <br /> 20 Mobile Lane Margaret Marci <br /> R, Wng Addmas Cky STAT! zr <br /> Cresent City CA 95205 <br /> APNs 79- l/ -02.E Ot>as� <br /> TMK0 PAWT BUAJNO btFo= Conpkto K Wng Party is diMarent from Projxwly Owner orFecl!Ity Oporator Men~above <br /> tlu="3�06NAttt Geological Technics Inc. AdenVorr arOwe of f <br /> c o Mar aret Marci <br /> UaftpAddmes 1172 Kansas Avenue PHON <br /> (209) 522-4119 <br /> CnV STATE 21P <br /> Modesto CA 95351 <br /> for fees sed dwrgeo OWNER FACUNIBUMNUS THIRD PARTY BILLING <br /> . >.d�mdereijaed Apptlnay ardy thot 1 am th.Owwr,�r,or d8t Srsiaen,asd,aelasvlelp lyt rn hAwnl�est� <br /> red TM4 Eiwwranov CM4Ress aadror Homrr reauwu mssdMW Wim dh apersth -Et batAhd w me atms address w the ACCowffAavarRsr Ear lhb d$:I ebo tartlly aw on <br /> hdoeandsa prevWtd on thb app9ndes h baa dad en ec and dint tU ng dated edhitla wR1 be pwhrmed IN mewdsom with aR*Ptlablr SAN JoAQuas Calwry OrMasote Cada aadAr <br /> staaeards dad STATt*WAer ptnuAL Laws dad ReNdatlom As me aadtnkwd aww opera1w w atsat or the property'-, - at the above fadsW/ate addrea,,tmby sae nd=the relewe of <br /> aoy dad to nwtb and esvhm amw a"Mmat I211 N SAN JOAQUIN COUNTV ENVIRONMENTAL IIEALTHEPARTMENr r woo Y b b aval!"and at dw same dw It b <br /> Provided"ar ar dry rgw"emadve. <br /> APPUCANT NAME(PLEAw Pat" Jenny Weese SIONATUNE <br /> TITLE Agent for Owner TAX ID -02 35 <br /> Dots tNAaa Oa/a <br /> IN& <br /> 11"U DATm AWuxT Pmo DATE oP PAynow PAv=W TVPE Recce"s CHLOR S REOENED By � <br /> SOS• <br />