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0 0 <br /> San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE El <br /> 4 Sep 2007 <br /> MASTER FILE RECORD INFORMATION "MFR" <br /> UNIT IV <br /> OWNER FILE' <br /> L'OAIP <br /> THEFOLLOkM61PROPERTY OWNERNFORNAT7ON. OaaO-OWNER CVANENILrQEMFN]rlI EHD <br /> pagppnyprrrtetpµHr Portof Stocklon PHDNe (209)946-0246 <br /> FkS1 Ari Lest <br /> Bu MNose Portof Stockton socsccl TAxiD# 84-6001402 <br /> OEwler Hrpoe Address 2201 W.Washington Street Da SUmaQp <br /> CRY Stockton sYArE CA 95203 <br /> o.,arr Plalutg Addy P.O.Box 2089 <br /> MaRing Addrem CRY Stockton stare CA 95201 <br /> I`sc nrrwr.1roc l <br /> [oarowtmn❑ Znmvnwu❑ PARRIE E) Fm AGMCN 011valx <br /> FACILITY FILE <br /> FAcxumlDN CAra,�RlrIP#; Ac wID# - 7HY7t <br /> Is this a NEW Basina%LocAnoN not DtevlouWv regulated bP the EmmommEUTAL HEALTH DEPARTMENT? Yes ❑ No Ix <br /> Ts this an E)OSTaie Business LOCATION but a NEw TYPE of regulated Business? Yea ❑ No x <br /> Bnm+MfFA�Y/SM NAME Building 312 and Parcel 27 <br /> 5Y APautas Reid Drive at Luce Avenue,Port of Stockton Snn u Bvsama PHONE i <br /> cm Stockton SrAn CA Zr 95203 <br /> thLL r',v. E+•d+"`�L'kfc. �•g� � j ,�y„�;`wy.'+�s)1?'" 'Y7"�A ` '-4 �w$IK'u' istl �In w e �� �,` <br /> BDAeb1IF DS1TI�r' LOgIIDH QI'M Y 4f�'Y' r�� J, �' r"t YFbr � l L t{h� i }.t <br /> Maeing Address JE0ff;7.RpA7f mFaaYIRyAAdrev at foobana/l <br /> P.O.Box 2089 Rita Koehnan <br /> MaRirg AddressCRY Stocktcn SIAn CA Za 95201 <br /> �t N <br /> ,IIC OaeE�. APrt if '�„� W' ))r•4 � G t� i£�13d;�1F�3'Q� t eYin 1}S4.j fi19$wri,"r 'nom viE(g£tli'tCb'�i �1 py�y�u i, <br /> THIRD PARTY BILLING INFO; COMPIeteif Billing Party is ElffereiMfiDm Property Owner orF8Cfffty OPeratnr kiaFlO dabove <br /> �p�.N,tHE AtbyRlan:mare tb (optlolDrj <br /> Mailing Addn%S PH w <br /> Cm' SrAn 77P <br /> A=wA7A2aRw rnr fres and charges OWNER FAcunYtOusiNEEs THIRD PARTY BILLING <br /> n u rnAmrt�N(T A^svnwrrnr Lehr vntleesgAN Ayplina4«ni(y tM lam Mr Onm,Operarnr.wAUNAriad.l,Kiu o/thv Bmm,as,arW lPdmea'bdg<(hpaAa Pc+ut?FVs, <br /> ptrAsnts',ErvPlaaarrnTarnacrs antltar OaL%rUux,:n Aswrleted wlu,tbk Apetntim wDl Oe bglNmP.at Nr Ptltlrm idmdfW PLAvru dss�tn*+rnrennAr�r(Ar M'e sites Idw rnrd$dni <br /> Aa mforamlioa preuidd Pe ehbappurndm if true and..4 nd ffi.1 are mubtd Pe %itla Kitt be rerraned m remtdaam Pilb are VpUSabb SAN JOAOum COtan Orftm CadnatWv <br /> SaandArds rad STAn aMlar FYDFRA1 Lewes and Reguladom. Asthe uetlrrsitPd oanv,Pperawr,pr oreero(IbA propem bated at+he Ahoy Tadlhyhltr addrol.ibrreby amberiae Me rdsaxM <br /> PPy aad 0.14 and mAi.,ESNW b SAN JO AWN COMM'D ViR[X:.1fMAL HEALTH DEPARTAIFP1T as aeaP w it b WA W rad et Me aamr time 4 k <br /> pru.;dd m..r mr rePre wL . / <br /> APPLICANT NAME Jetlrey Wingfield PLrwsE PaWr SIGNATURE <br /> TITLE Environmental Manager DwvER'SLICENs[a <br /> (PHOroroPr AraurrrPl <br /> Appmwd 6Y Whi AwWALtq Oln¢Pnrnabp remPkmd 81' Date <br /> 29A002 April 3.2003 <br />