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06/04/99 FRI 15:53 FAX 209 948 0621 KLEINFELDER INC 10 003 <br /> 51 <br /> MASTER <br /> DArE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> RW_EO MEq rOR ENO FO`_ <br /> UNIT IV <br /> OCYSd°of OWNER FILE <br /> :OMFLEI`E rNE FOLLOWING PROPERTY OWNER INFORMAT/ON: <br /> CWECN/F OWNER CUaaENRYON F/LEW/rMEHD a <br /> PROPERTY <br /> OWNER NAME PHONE <br /> FYn MI <br /> 4i! <br /> BV91NE9a NAME <br /> SOC SEC/TAX ID M <br /> Owner Home Address <br /> DRIVER'S LICENSE s <br /> City <br /> STATE Zip <br /> OWMr Mailing pddrna <br /> s <br /> Melling Address City ��y•-- <br /> 5�� /J� Stale Zip <br /> 0 <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP E3 <br /> FACILITY FILE� <br /> FED AGENCY 11 OTHER O JJ //ppY�••Apet <br /> lit1:11211 ', .. IC <br /> %OMPLEIE rNEFOLLOW/NG BUSINESS I FACILITY/SITE /NFORMAr/ON' <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 <br /> YES'K No Cl <br /> la this an E1(ISTINO Business LOCATION but a NEW TYPE of regulated Business? <br /> YES ❑ No <br /> 8!7ESs/FACILITY/ <br /> SI NAME <br /> 000se� Ilar�e 17nofi �e, C� -1a5 ( V �� t 10+) <br /> SITE ADDRESS '1 'A-1y.U1TEq BUSINESS PH[�E <br /> 21ti` i lP��(n A_9n��'i dG Ilio f //�1 ,tl'ItL'Ln' I•V, W <br /> 5 1 1 STATE ZIP <br /> Melling Address 110IFFERRENr/rom Facility Address <br /> -Di 1 LA 5 A Mac Attention: or Care Of(optional) <br /> �D(Tl , A rt-�� ��c k ►`�lcu�n yrs <br /> dalling Address City (� ��� /, �� / !•/� <br /> /� <br /> �' U/� (�✓"rl BlV(� O\WI[ `/r [yn� <br /> qt�Ejq ZIP <br /> ' .. EWA .. . I ,.,, i, fsrl:.^fie' `,y ..;}I <br /> ilao PARTY BILLING INFO: Comp/ale N Billing Party is different from Property Owner OF Facility Operator identified above. <br /> 3U91N s9 NAME <br /> C . <br /> Attention:OrCare Of (optional) <br /> IL S <br /> Malling Address 3 I GU ZG <br /> /�j/ l� PHONE �' ! lO �✓✓OI� <br /> ;Iry OI/ �l..P L STATE Zip ry <br /> 112OUNr.rlaepF.es for fees and Charges OWNER FAcluTY/BUSINESS THIRD PARTY BILLING <br /> .UNC AND COMPLIANCE ACHNOW LFUGMENT: I,the undenll;ntJ AppI1Gn1,fMify IhM I qnl the(APndr,(l/lern/nl,grda//lerlrrd ARrnl of Ihi3 Ilnalnfaa,gnli I gfhnnH'IMIEf IIInI qII <br /> V11 FE PENALnEr,ENFr1RC'eAIENTC/U9GEtand/or/I(IDRGYC/IARCF_r nasorlslyd with/hB oPrnlion will hr hlllcrl to mr ql/be gdJraa IJenllRrd gbm'e na Iilr ACC'aUNTAIIIIgEta <br /> Ihb aIle. 1 daa eedlfy Ihql qll bdornullan provided on Ihla gpplicgllon h Irue qnd rowed;And Ihql dl repnlAleJ Adivilln Rill hr perforn/nl in nccorJRnfe nilil qll gppllrgMr SAn <br /> DUIN COUNty Otdlggnce Coda gndlar StnnJuds And S'rATIE qnd/or FEDCMI,lnwa And RegnlRllona. As the nnJenlgnrd owner,operator,or ngenl of the prnprrly Meg1eJ ql Ihr <br /> ve f�dlhy/she. drcsa, 1 herchy wlhorlu Ihr relcasr.Sr Any ad .11 rnnlLr qnd cnvircnmenlnt nnsessmenl Informgllon In SAN JOAQLIIN COLINI'1' ENVIHONAIENI'AL <br /> 1LT11 DIVISION qa soon qs II b■vgililble qnd al the agmr Ilene II Is provided la me or my rcprceenlgllve <br /> PPLICANT NAME PLEASE PRINT <br /> —�Gill� �L—�sF�lf�if/.�/C/�!�_ SIGNATURE¢' <br /> ?LE DRIVER'S LICCEEENSE'# <br /> •pr�r/eaB➢&EI�SSk>✓'�:..�I Rafx3�af �d/sra— ra�L,, <br /> ..._ <br />