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- art nt \ M <br /> San J;,�quin County Environmental Health",( 2Q12 1 <br /> "MFR" <br /> UCGREENFORM <br /> DATE 04 October 2012 MASTER FILE RECORD INFORMATION &LOP <br /> ^�-, AR END O OWNER ID# CASE# 6`tlV� IJ IV <br /> OWNER FILE:COMPLETE 7NEFOLLOwA(G PROPERTY OWNER INFORMATION.' offEcafF OWNER CURREMLYONFILERTnf END� <br /> PRoPERTIYomer NAME Tarditi Rentals.PTP (209)931-6000 <br /> FirstMI Last PHOKENUMBER <br /> EiMILAODRESB <br /> 13-unsSNAME T & T Trucking <br /> osmer Ham a Address 11396 N. Hwy 99 <br /> STATEnP 95240 <br /> Oft Lodi CA <br /> oW rmalwmAddress as above ,. <br /> Melling Address City as above Stats ZtPl <br /> CORPJRATK»l❑ INDtWDDAL❑ PARTNERSHIP❑ FEDAaENLw❑ OTHER® <br /> SITE MTOATION_ENVIRONMENTAL ASSEMM NT VOLUNTARY CLEMIN,_WATER QUALITY_HW PIPRUNE INVESTIGATION_LOP_ <br /> f <br /> FACILITY ID# INV# Accou ID .PR#/ O ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQC8 DTSC_SPA_ <br /> P1Qd� I JOkBA i <br /> FACILITY FILE COMPLETE TNEFOLLOW/NO BUSINESS/FACILITY/SITE/NFORAwlo .' 1 <br /> Is this a NEW BUSinese LOCATION nOt previouSly regulated liy the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an BasnNis Business LOCATION beta NEW TWE of regulated Business? YES ❑ No IKI <br /> BuSINESSilewl-11VISQENAME T & T Trucking <br /> Sm AOOREe9 as above Suites BuSINESSPHONE �I <br /> Cm. STATE LP <br /> 1 ' / <br /> BOARD OF SUPERVISOR DISTINCT H LOCATION CooE KEY1 .. KEY2 <br /> MeiRlg Address NOIfFEROfffson,Fadi NIDAddrees Attention:arCare Of toptlarmp <br /> Nailing Address City STATE ZIP <br /> t <br /> SICOODE APN# COMMENT: <br /> o5c/- Z('0 /0 <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner of-Facility Operator identified above. <br /> I BUSINESS NAME Tarditi Rentals PTP Attention sarCare Or(apBoW <br /> Melatg Address 11396 N Hwy 99 PHONE 209-931-6000 <br /> Clry Lodi STATE CA LF <br /> I <br /> AccainfeAaamm <br /> for fees and charges OWNER FACRITY/BUSINESS x THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: L the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMII'FEE.c, <br /> PENALOEI,ENFOFCEMEMCHAarE.V muI ar 110uaf.r CNARf££assaciateN with this operation will be billed tome at the address identified above as the ACTIM'A/IIMES£far this site. I also certify Mat <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> jStandards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN soon.e is vailable and at the same time it is <br /> provided in me or my representative. <br /> APPLICANT NAME(PLEASE PLANT) TerryTarditiTITLE <br /> srowuuR <br /> TAx ID# <br /> By DMe A mm ng Oska Prooamh g Comphted By Deb <br /> $ITEMITIGATION AlsouRr PAID DATEOFPAYMENT PAymeMYTYPE RECEIPTA CHECK RECEIVED BY WORK PLA/N PE <br /> FEE:= 3S Zp <br />