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<br /> DATE Nov . 4 , 1 9 9 7 MASTER FILE RECORD INFORMATION FORM (EH0015(REVISEDOW111971)
<br /> SNAOED ARES FOR EHD U6E N
<br /> UNIT IV
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<br /> OWWER FILE
<br /> COMPLETE THEFOLLowwG BUSINESS OWNER INFORMAT)ON. CHECK/F OWNER CURREA/TLYONFxEiWTHEHD
<br /> BUSINESS Stockton Unified SchooL'• "istrict PHONE
<br /> OWNER NAME -----------------=-------.___--------
<br /> (209) 953-4452
<br /> ...................................... !st.......................................M!.....................................•...••....1,.t1.3.t................................•_•_
<br /> BUSINESS NAME(If dhTerent from Owner Name) Same ? SOC SEC I TAx I D#
<br /> OWNER HOME ADDRESS Facilities Services , 1932 N , El P i n a l , ; DRIVER'$LICENSE#
<br /> city
<br /> Stockton STATEzip�P95205
<br /> OWNER MAILING ADDRESS (if D1FFERE/VTfram OwnerAddress) Attention:or Care of (optional)
<br /> same
<br /> Mailing Address City State Zip
<br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ LOCALAGENCYM COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑
<br /> FACILITY FILE
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<br /> COMPLETETHEFOLLOWJNG BUSINESS / FACILITY/SITE INFORMATION:
<br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ NO ❑
<br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YEs W No ❑
<br /> BUSINESS/FACILITYISITE NAME Stockton U n i f i e d School District
<br /> SITE ADDRESS Facilities Services , 1932 N . El P i n a l i SUITE# BUSINESS PHONE
<br /> :(209) 953-4078
<br /> clrr Stockton sTATECA : zip 95205
<br /> Mailing Address ifDIFFERENTfmm F—ddyAddress same Attention:or Care Of(optional)
<br /> Mailing Address City E STATE zip
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<br /> THIRD PARTY BILLING INFORMATIoN: Complete if Billing Party is different from Business Owner Identified above.
<br /> ..........................................................................._............................................................................................................,...................................'.........................................................................
<br /> ,
<br /> BUSINESS NAME same Attention:or Care Of (optional)
<br /> Mailing Address PHONE
<br /> CITY STATE ZIP
<br /> ACCDUNTADDREss for fees and charges OWNER FACILITYBUSINESS THIRD PARTY BILLING
<br /> BILLING AMD COMPLIANCE ACI.NOWLEDCME`fT: I,the undersigned Applicant,ce that I am theerator,or Authoriyed Agent of this Business,and I acknowledge that all
<br /> PERNrT FEES, PE.NAmES, ENFORCEMENT CHARGES and/or HOURLY CHARGES assocl this operation will be billed to me at the address identified above as the ACCOUNT
<br /> .-ADDRESS for this site. I also certifv that all information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all
<br /> applicable SAN JOAQUIN COUNTY Ordinance Codes andlor Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property
<br /> located at the above facilitvlsite address I hereby authorise the release of any and all results and environmental assessment on to SAN JOAQUIN COUNTY
<br /> ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representativ
<br /> PLEASE PRINT
<br /> APPLICANTNAME GEORGE E . RIDLER SIGNATUR
<br /> TITLE Deputy Superintendent DRIVER'S LICENSE#
<br /> IpHnTncn
<br /> ...............
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