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San Joaquin County Environmental Health Department <br /> DATE S / MASTER FILE RECORD INFORMATION "MFR71 GREENFORM <br /> '7 _ SITE MITIGATION& LOP <br /> SHADED ARF FGR EHD USE ONLY DWNEn ID# CASE#. - UNIT IV <br /> OWNER FILEXOMPLE7E THEFOLLOW/NG PROPERIYOWNER lwowwww Cxecxry OWNER CuwaexfcroxnLZWr EHDEl <br /> PROPETm ONNeat NAME Ken Gillies 209) 948-6268 <br /> First MI Last PHONENIMBER <br /> BUSINESSNAME Gillies Trucking E-MUIILA1HX ESS <br /> Ovnerli me Address P.O.Box 8303 <br /> CRY Stockton STATE CA ?Jp <br /> 95205 <br /> Owner Malling Address Syme As Above <br /> MallhMAddresa City Same As Above Siete Zip <br /> CORPOMRDN X INDIVIDUAL❑ PARTNERSHIP❑ FEDAGENCY❑ OTHER <br /> SrM MMGATiON_ENVIRONMENTAL ASSEWMZNT OWNi uP_WATERQUALFTY_HW PIPaUNE INvEsnGATION LOP <br /> FACILfO'ID# Ixv# Accauxi lD 4MWRO# ASSIGNED EMPLOYEE LEADAGENCY:EH WOCB_DTSC_EPA_ <br /> @�OD31�q N Gln Mi <br /> FACILITYFILE COMPLETE 7HEFOLLOW/NGB SINESS/FAC ITY/SITE/NFORMA77ow <br /> Is this a NEW Business LOCATION not previously regul the EN NMENTAL HEALTHDEPARTMENT? Yes ❑ No X <br /> Is thisan EwsnNGBusiness LOCATION buta NEwTYPEof regulated Business? YES ❑ No X <br /> BUSINEWFACILMISITENWE Gillies Trucking <br /> SNEADDRE9S 3931 Newton Rd. D SurrE# BUSINESSPHONE <br /> Cm Stockton 3sa� STATE CA ZIP 95205 \� <br /> BOARDOFSUPERAWFIDISraIOr LOCATION CODE KEYt KLY2 1 <br /> Ma11Mg Address IMFFT:REWrf mFacIfdyAddiaas Attention: rCam Of(Ppdavtaf/ <br /> MaIlIng Address City STATE zip <br /> SICCGoe APN# � CDMINFNI: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orleacility Operator identified above. <br /> BUSINESS NAME Technicon Engineering Services,Inc. ANerlSon:"Cam Of tootWW <br /> Mailing Address 4539 N.Bmwley Ave.,Suite 108 PHONE (559)256-3222 <br /> i <br /> Cm Fresno STATE CA LP 93722 <br /> AfdaQ/AVAOOHE84 forfeesand Charges, OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> 11MUNG AND COMPLIANCE A(XyoyyLCDGME W: I,the undersigned AppU.4 certify that I am the ONwn,Opemmr,or AafkarcedAgent of this Business,and 1 acknowledge 1112t3l!PMV fFEEt, <br /> PENALHES,ENFORcarENTCNARGES and/or HovArCe cesusociatei with this operation will he billedto meat the addressidentifiedabove u the ACCOUWADDRESS for this site. I arm certify that <br /> all information provided on this 2PPUM600 is true and correct,and that w regulated activides will be perfarmed in accordance with all appBcable SAN JOAQM CUUx1Y Ord ante Codes and/or <br /> Standards and STATE and/or FtDF.R1L Laws and Regulations.As the undersigned owner,opemmr,or agent of the property located at the above facilityfsioe address,I hereby authorize the release of <br /> any and an rendis and ensimmneaad assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it b <br /> provided to me or my reprrsewentive <br /> APPLICANT NAME(PI-EDarren G.Williams <br /> ASEPR w) SIDMTune <br /> 7rTLE President&CEO Technicon Engineering Services,Inc. TAX ID# 7702094/8 VW <br /> Approved By Dale - Accounting(rifice Prvcessbg Cemplateday c, Data <br /> SIEMMGA AMODNTPAID DArEoFPA E PAYMEHTTYPE RECe"If CHECK# REC VEO BY WORN PIAN PE <br /> FEE: e <br /> MU � <br />