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San Joa uin count* <br /> ount blic Health Services Environmeoiealth Division <br /> GREEN FORM <br /> DATE qt, ,D J MASTER FILE RECORD INFORMATION "MFR" UNIT <br /> • OWNER ID# CASE# UNIT IV <br /> OWNER FILE <br /> CHECK/F OWNER CURRENTLYONFILEWITHEHO ❑ <br /> COMPLETE THEFOLLOW/NG PROPERTY OWNER /NFORMA^T/ON. <br /> r1BusiN!EssNME <br /> NER ,5w j /� PHONE^ , <br /> /✓'J (i/ / {/7'J <br /> First MI lest Zoe <br /> SOC SEC/TAX ID# <br /> SAN JOA UIN VALLEY ASSOCIATES <br /> Owner Home Address 2333 SAN RAMON VALLEY BLVD DRIVER'S LICENSE# <br /> city SAN RAMON STATE OA LP 94903 <br /> .mss = v State Zip 5� <br /> � ! ' D <br /> -709 .73 <br /> r:npOnRGTInN❑J1n INnlvin,lel ❑ PARTNFRCNIR FFn AaFNr.V❑ffo <br /> nTNFR❑ <br /> Fern�Tv In A [:Roca RCF In# Arrn I.T In# I•oiN <br /> OMPLETETHEFOLLOWJNG BUSINESS I FACILITY/SITE INFORMATION.- <br /> Is <br /> NFORMAT/ON.Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES ❑ NO p <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business Z YES ElG <br /> NO A <br /> BUSINESSIFACILITTISITE NAME / S �I�✓.NA er O /Ley � <br /> RRIDGEROBT TRAITS DEVELOPMENT <br /> SITE ADDRESS — 19oy / . / /�/ r(- _ /-/`�( E# USI(N yE93`rPHTON`E <br /> CITY STOCKTON STAASTE CA Z 95206 <br /> IIBOARD OF SUPERVISOR DISTRICT I I LOCATION CODE I I KEY1 I I KEYZ I II <br /> Mailing Address ifDIFFEREAfrfrom Facility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> RIC Cnnr I API n - CnuucnT - - <br /> THIRD PARTY BILLING INFO; Complete if Billing Party is different from Property Owner orFacility Operator identibed above. <br /> BUSINESS NAME GLEN SPRINGS HOLDINGS, INC. Attention:orCare Of (optional) <br /> KEN PRICE <br /> 9ARn FORTUNE DRIVE STITTE 100 Mailing Address PHONE <br /> Cm STAT` KY ZIP 40509 <br /> LEXINGTON <br /> ACCOUAtTADDRESS fnrfaaR and nharnas OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> R Nn('nmPl ISNrF ArRNnwl Fnr.MFVT; 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PEN'ALTIEs,ENFORCEMEAT CHARGES and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the ACCOHNT AOURPCC for this site. I also certify that all <br /> 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 /> Standards 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 DIVISION as soon Rs it Is available and at the Same time it is provided to <br /> me or my representative. <br /> PLEASE PRINT �j i 7' T f4 <br /> i. SIGNATURE (Yr CVYVC(�Q 0.tµ�Vy}"Wd 7�CGy! <br /> APPLICANT NA (,, O N <br /> DRIVER'S LICENSE# <br /> TITLE <br /> ADuroved By nate Arrnu,.Nnn nlrnp Pmreaainn Cmm�latwd Ro natty <br />