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wt'l Mr � Xt Ina r T 'lYi�`OJ4 .S't1' ST tMS <br /> • .�.'.�.. ° lSat�I:Jn3 i _'1i51°,�. T'f« a1C ..al.. ,n i: Elf!Y ;,,, r171R:. <br /> rOR1A IEH f1DtRRtrudeT00n tN7) <br /> DATE MASTER FILE RECORD INFORMATION <br /> p.. .n.r«n..eo... Mi tt:I'�.h'♦1 IF.Ti it i�. '�:I'�1♦ Wit' ra• r 4 t <br /> TCOYIIIS» e UNIT IV <br /> / 1dH 1,11'.1. <br /> OWNER FILE <br /> COMPLE7_E__T_NEFOLLOWING BUSINESS OWNER INFORMATION: CxEcx IF OWNER CuaRENn.rOwnLEwnNEHD <br /> ... <br /> ............... .._-.—._..-__.._.._....__•.•_«____ ..—..•«_..«_.�..__•___•_•_•__•__._ ..,.__........ _ .. ._ _.«__........... <br /> Bus,NEss Tracy Sizemore ' PNONE <br /> OwN1.71 NAME ----___«r«___—___--___--.________—_, <br /> _.........-.....................___.-_......-.__._,ag___._..r_..—.___!Y..._........_..... <br /> ._....._____{?^_.—.—.—__•__^' <br /> euwNEss NAME(NdiRdrwdfixVa OWnbr Name) for the Stockton Group IsOC SECf TAa IOt <br /> OWNER HOME AbOAESa ORIVEA'S UCENSE <br /> ''. rale STATE ! LP <br /> OVO4ERMWLINGADCRESa (ifOfAF ENTOeee OrnbrAdd/aes) ' At1enEOn:dercarb 01 ( <br /> 1338 Phillip Building Tracy SiMd"re /tlillips Petro1e <br /> Maatrig Address city Bartlesville sate CA zip 74004 C <br /> CORPORATIONO INDIVIDUAL❑ PAMNERSHIP0 LGCALAGEJICYC Ccuwrr AGENOr0 STATE AGENCY FEQACENLTQ OntEltYa1 <br /> FACILITY FILE r <br /> COMPLErrrn.-FOLLOW)NG BUSINESS I FACILITY/SITE INFORMATION; <br /> Is this a NEW Buaincaa LOCATION not Previbtply rugWated by the ENVIRONYIXfAL HEALTH DIVISION T yes O NO gyl <br /> Is tho an Fm snNG Bmineas LOCATION but a NEW TYPE Of regulated Btuinbse i YES C NO f9 <br /> BUsrNES3/FACIUT7ISITENANE The Stockton Group <br /> SITE AppRE93 504 Weber Avenue sUnEM BUSINESS PNONE <br /> 17 Lincoln Street (Empty Lots) <br /> LTT <br /> ST TIP <br /> Stockton C�A 95202 <br /> aid. W <br /> Mailing Addreas rfDIFFQRPNTII o nFaeibfyAddi Attention:pq-Cam Of(opcimel) <br /> Mailing Address City i STATE 1 zip <br /> i.;P W's J,t <br /> I�' 1 <br /> t tp <br /> ....i.. '�'1,Ivw. )I.'M <br /> THIRD PARTT BILLING Mrc . ----__....__...-- — — .... _ — _._..__�... ........ <br /> -- <br /> BUSINESSNAIVE Anentibn!OrCamOf f°vb°r`a0 Jon Rosso <br /> Clayton Group Services <br /> Mailing Addreay 6920 Koll Center Parkway, Suite 216 PNONE 925 7426 . 2600 <br /> DI^' Pleasanton sTATE CA aP 94566 <br /> dgcgfAA/TAOORE93 for fees and charges OWNER FAcLrrrlBuswoe: THRID PARTY BILLING <br /> DIt. NC.WO COMr1.rANLT:ACIC!(AVLttCM"T: I.the ondiragned.Appliranl,certify that I am the 01. .Qvn,r ,.or.{Mdur:rdAite ofthis Business,and I acknor,ltdet that aB <br /> PFRuTT FEES. P£NaLT£s, ExrvffM%Z.W CUFtM,:t and/or HOUALr C E C£s----tented pith this operetioe will be billed to an addreaa Wcnliried above u the A[[n1/vr <br /> ndre for this site. I also rertlfv that all information provided on rhia application u true and corvar, and that t will be performs/ in accordance with 4 <br /> apPliMble SANJOAQULV COIP.ITY t'hdina Calc and/or StvWXrda and STATI:and/or FEDEM Lam ae a omtcr,opartor.r agent or the propern, <br /> Wxcd at the be. farilirvhite addr I hereby aurh.rbe the ..io.te of any and all reaWla en, infnrmngn to SAN JOAQt," COCNTY <br /> CNVTRONMFNTAL MA-LTH Dr VISION at soon-it u available arld x the same time it u pemidM to LV <br /> prve"wir . <br /> / PLEASE PRINT /� <br /> APPLICANT NAME .. V 4/7. x Y Cy -�L . SIGNATURE [21u. 'W?, u-�— <br /> TITLE _ � (�Z` DRIVER'S LICENSES /2/O <br /> e��rYC�T <br /> I 55 � ! y i tI t ',z:a L��.<,..,:,i 11 ♦t w <br /> AOPFoa'ed.:�Y .. .. .i`.w. bats;:.: ....I ix„ . + IleGobnwna'OtAOx Yrpdowd ` '•.. �, raMe 1'' -..♦ a °i t t 4...tw S p. <br /> BttiOntdleked9Y <br />