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San Joaquin County Environmental Health Department <br /> DATE June 30, 2010 MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> SHAQED AREAS FOR EHD USE ONLY OWNER IDS CASE S UNIT IV <br /> OVMER FILE <br /> COMPLETE THEFOLLOWNGPROPERTY OWNER INFORMATION; CHECKIF OWNER CURREA?LYONnLEW17N EHO <br /> PROPERTY OWNER NAME PHONE <br /> First MI Last <br /> BUSINESS NAME SOC SEC/TAX IO S <br /> Owner Home Address DRIVER'S LICENSE <br /> City STATE ZIP <br /> Owner Meiling Address <br /> Mailing Address City State Zip <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID* CRoss REF ID* ACCOUNT ID O Iwo <br /> COMPLETETHEFOLLOW/NG BUSINESS I FACILITY/SITE INFORMAnom <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINEss/FACILrrY/SrmNAME Metalsa <br /> SITE ADDRESS 1550 Industrial Drive Surm uslN ss PHONE <br /> 20-9$3-6100 <br /> Cm Stockton STATE CA ZIP 90206 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 K-2 <br /> Melling Address IfDIFFEREA?from FacdKyAddress Attention:or Care Of(opHoriell <br /> Mailing Address City STATE: ZIP <br /> SIC CODE APN* COMMENT: <br /> THIRD PARTY BILLING INFO: Complete ifBil ling Party is different from Property Owner orFacility Operator identified above. <br /> BUSINESS NAME Attention:orCars Of(ophlarmg <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> AccoumrADDREsa for fees and charges OWNER FACILITYIBusINESS THIRD PARTY BILLING <br /> BILLING.%ND COMPLIANCE ACKNOWLEDGMENT: I,lire undersigned Applicant,certify that lam the L)wwer,Operator,or.luthoriwaf.-1gen1 of this Business.and I acknowledge that all PERun I-Eta', <br /> PENAI TIEY,ENFORC.FsIFVr 01 lRbFS anti/or But'RI.Y 01ARf.'FS associated with this operation w ill be billed to meat tire address identified above as the ACYUL yT.4bORF.C4 for this site. I also 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 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 aut orize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENN'IRONNIENTAL HEALTH F:IRTSIENT as soon as it is available am a the same time it is <br /> provided to me or my representative. _ 1 <br /> NICOLAS VILLARREAL M. PLEASE PRINT 'I <br /> APPLICANT NAME SIGNATURE <br /> TITLE DIRECTOR DRIVER'S LICENSE# <br /> 1PHOTOCOPY REQUIRED) <br /> Approved By Date Accountlnii 11ce Processing Completed By Date <br /> 29-02 10112:07 MASTER Fit_E RECORD-GRFF;\ <br />