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l <br /> San Joaquin County Environmental Health Department <br /> DATEk 3 , 12 . 0 8 `� GREEN FORM <br /> MASTER FILE RECORD INFORMATION MFRF'v <br /> OWNER ID# IFOCASE# - UNIT IV <br /> lJ Doc) b <br /> OYYNER FILE <br /> COMPLETE THEFOLLOWMGPROPERTY OWNER INFORMATION; CwcKIF OWNER CURRENTLYONFrLEWrTH EHD <br /> PROPERTY OWNER NAME PHONE <br /> First W Last <br /> P---NAME City of Stockton - SOC SEC/TAxID# <br /> Owner Home Address 425 North El Dorado Street DRIVERS LICENSE# <br /> city Stockton STATE CA Z- 95202 <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> Ti]PF AF AWNFRCHTD <br /> CORPORATION❑ INDMDUAL❑ PARTNERSHIP.0 FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# �O CROSS REF ID# ACCOUNT ID# rZ 3. INV# <br /> COMPLETE THE O LOWING BUSINESS I FACILITY SITE INFORMA770111- <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an E)a5TiNG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FACILITY/SrrENAME Intersection of Lower Sac. Rd. and Union Pacific Railroad <br /> SITEADDRESS 102.00 Lower Sacramento Road SUITE# BUSINESSPHONE <br /> CITY Stockton SATE CA zip 95210 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYS _ - - - KEyZ <br /> Mailing Address NDIFFERENrfrom FaciWAddress Attention:or Care Of(optional) <br /> Mailing Address City <br /> STATE ZIP <br /> SIC CODE APN# COMMENT; <br /> THIRD PARTY BILLING INFO; Complete if Billing Party Is different from Property Owner or Facility Operator identifiedabove. <br /> BUSINESS NAME Blackburn Consulting Attention:orCare Of (optional) <br /> David Castro <br /> Mailing Address 4622 Glass Court, Suite A PHONE 209-522-6273 <br /> CITY Modesto STATE CA zip 95356 <br /> r a UMESS for fees and charges <br /> OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> RIi.I.ING ANTI rOMPI_IANCE ACKNOWI.FnGNIFNT; 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERAfITFEF-5, <br /> PENALTIES,ENFORCEhfENT CHARGES and/or HOURLYCHARGES associated with this operation will be billed tome at the address identified above as the ACcot NTADim 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 authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as't is available and at the s2. a time it is <br /> provided to me or my representative. <br /> APPLICANT NAME David Castro PLEASE PRINT SIGNATURE <br /> TITLE Project Engineer DRIVER'S LICENSE# B5971849 ' <br /> (PHOTOCOPY REQUIRED) <br /> Approved By Date Accounting Office Processing Completed By �.r� Date <br /> 29-02-002 April 25,2003 <br />