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San J00in County Environmental Health Oartment <br /> 11 GREEN FORM <br /> DATE ' NOV. 11, 2004 „ fl <br /> MASTER FILE RECORD INFORMATION MFR <br /> Gumcn eecec[ne FNII uc[rlw v <br /> OWNER FILE <br /> COMPLETE 7HE FOLLOWING PROPERTY OWNER INFORMA77om CHEctrrF OWNER CURRENnYONFrtE WrTH EHD <br /> PROISMOINNERNAME PHONE 209 931-5157 <br /> First MI last <br /> BUSINESS NAME CHINCHIOLO STEMILT CALIF, LLC/SIERRA HILLS PACKING, INC SOC SEC/Tax ID# <br /> Owner Home Address PO BOX 55096 DRIVER'S LICENSE# <br /> city STOCKTON STATECA u° 95215 <br /> Owner Mailing Address <br /> SAME AS ABOVE <br /> Mailing Address City State rip <br /> TVPF OFnwwcacwrP <br /> CORPOMTDJN❑ INDMDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID At By -6 2lJ e CROSS REF ID# AccouNr ID# 3/ INv# <br /> COMPL E IJ t� <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ Nop <br /> BUSINESS/FAaLTy/SITE NAME CHINCHIOLO STEMILT CALIF, LLC/SIERRA HILLS PACKING, INC <br /> SITE ADDRESS 4799 & 4505 NORTH JACK TONE ROAD Sum# BUSINESS PHONE 209 931-51 5 <br /> QTY STOCKTON STATE CAW 95215 <br /> Mailing Address ifDIFF£RENTfrom Facility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE zip <br /> THIRD PARTY BILLING INFO; Complete if Billing Party is differentfrom Property Owner or Facility Operator identified above. <br /> BUSINESS NAME NEIL O. ANDERSON & ASSOC., INC. Attention:or Care Of (optional)DAVID WELCH <br /> Mailing Address 902 INDUSTRIAL WAY PHONE 209 367-3701 <br /> CITY LODI STATE CA 7P 95240 <br /> Arrmtur ADAV-VTI for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Bu 11M Asm COSIPll\\CF A('N\O\YLFnG]IENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this BuH and 1 acknowledge that a ERMITFE'E.\', <br /> PENALT/FS,ENFORCEMENT CHARGES and/or HOURLYCHARGER associated with this operation will be baled to me at the address identified above as the fort aho certify that <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 /> Standards and STA rE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,l hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR T as " <br /> as <br /> R.aand at the same time His <br /> provided to me or my representative. PLEASE <br /> APPLICANTNAMEASSOC. RINr SIGNATOR nII q ./ <br /> NEIL O.ANDERSON & ASSOCINC. IJQ �(/I/ available�- �/��P��/J�j�'I',�Q/��Jj�(j <br /> TITLE DRIVER'S LICENSE# <br /> CORPORATION (PHOTOCOPYREOUIRED) L/vICN� <br /> Approved By I Date Accounting Office Processing Completed By Date ! <br /> 29-12-0113 April 35,'_Utlt <br />