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San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE 3/15/04 - <br /> MASTER FILE RECORD INFORMATION IIMFRI' <br /> cus..cn eece mo cHn ,ccnxrr OWNERID# CASE# UNIT IV <br /> OWNER FILE <br /> o/ECKIF OWNER eoRRetm.rax Elle FVITrr END El <br /> COMPLE7E THEFOLLOWING PROPE RTY OWNER INFORMA770N: <br /> PROPERTY OWNER NAME Russell Ka ehiro P""NE 209-835-9491 <br /> Fiisl MI Last <br /> BUSINESS NAME SOC SEC/TAx ID# <br /> Jepsen Webb Ranch LLC <br /> Owner Horne Addrett DRIVER'S LICERSE# <br /> 7200 W. lith Street <br /> City Tracy CA ZP 95377 <br /> Owner Mailing Address Same <br /> Mai(ng Address City Same State Zip <br /> Tvoc nrrNuxrccu,n VV11ss <br /> CARPORATION❑ INDIWDUALEX PARTNERSHIP❑ FEDAGENCY❑ OTHER <br /> FACILITY FILE <br /> FAaurrID# CROSS REF ID# ACCOUNTID# INV# <br /> MPLEIE THEFOLLOWING BUSI N ESS I FACI LITY I SITE NFORMATION' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESSfFAaLRY/Srrs NAME LJe sen Webb Ranch LLC U$eo <br /> Oc ( ✓E Yr <br /> SMADDRESSAPN 209-240 -26,27. 115 Acre 0'W. of Valpico Rd/ ammers5uyk'ry SINESSPHone N/A <br /> N/A APN 209-240 -30. 5 Acre 5000'W of Val ico Rd Lammers Ferry Rd <br /> X19 Tracy STATE <br /> CA 'P 93577 <br /> BOARDOFsUPERVLSOR Dues RICe LOfATIONCODE KEYI KEY2 <br /> Mailing Address ffOIFFERENTfmm FaciiityAddress Attention:or Care Of(Option/) <br /> 7200 W. 11th Street <br /> STATE ZIP <br /> Mailing Address City <br /> Trac CA 7 <br /> [SICCODE APN# COMMEND <br /> THIRD PAI rY BILUNG INFO: Complete if Billing Party is different from Property owner crFacility Operator idendfled above. <br /> BUSINESS MIME Attention:orCam Of (ophonal) <br /> Kennedy/Jenks Consultants Mike McLeod <br /> Mailing Address PHONE <br /> 622 Folsom Street �I� 415-243-2150 <br /> STATE ZIP <br /> oD San Francisco CA 94107 <br /> A =uAx Annneee for fees and charges OWNER FACILRY/BUSINESS THIRD PARTY BILLING <br /> i' <br /> MCOMPTIANCFACKNONNI,n NIFNT: I,the undersigned Applicant,certify that I am the Owner,Opvasor,or lurhorited Agent of this Business,and I acknowledge that all PsworFm, <br /> P£NAITIEY,DVMRcS;IIovr0u GEs nrd/or ROURLYCILLRGEe associated with thisoperation gill be billed to meattheaddress identified above as the Ars'nrm, annRscs for this she. I also certify that <br /> all information Provided on this application is true and correct;and that all reguloled activities will be performed in accordance with all applicable SAHIOAQIILYCO M Ordinance Coda and/or <br /> Standards and STATE andror FEDERAL LNwsand Regulations. As the uminsigned owner,operator,or agent of the property located at the <br /> ms/af�b�ovv/eefaciiityhhe address,I hereby authorbe the release of <br /> any and all results and environmental assessment infennation to SVN.IOAQIIIN COL97y E:YVIRONN E\TAL HEALM DFPA� ' r � <br /> ntaxlable an�same time it B <br /> provided to me or my representative. PLEASE PRINT 55 //[•, /,{l't/�`, <br /> APPLICANT NAME Michael L. McLeod for Musco Family Olive C(IIGNATURE <br /> TITLE <br /> DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIRED) – — <br /> Geologist - <br /> Approved By D t A ountin9 Office Prxessin9 CanPleRed BY Date <br /> ••29-02-002 ApId 25,2003 . <br />