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ft <br /> REGEIVFr4.1?: 1 1 FM WW "Vw No. 4602 P. 2 <br /> I" T M114 San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORK <br /> SITE WrICATION&LOP <br /> E'''P "��I� CA6EM' UNIT 1V <br /> o+MNEie ID, <br /> OWIER FILE:COMfPLETETNEFOLLOWIYG PROPERTY OWNER lwomwlom Cft5Ck1r OwNEV?CuRRENUYONFaE*flN ENO 0 <br /> PitoPERtrpw 01 MAW Blinco Trucking <br /> Fk3f MJ test PHonNWteEa - <br /> BUSirtESBN-E Blinco Trucking &FWLAo0tom <br /> owti•i-Nome <br /> ' M East Mariposa Road <br /> e"t Stockton A'E nP 95205 <br /> Ownsr rdyffing Addrrvv Same <br /> M>A-M Addrtaa Cft,y(( , zip <br /> CO"ORATION IN NONIDUAL❑ PARTNERMP❑ FED AOAN&❑ 4ritvt❑ <br /> $M ONM"TION ENVutONYYWAL As3ESSMENT VOLUICrAKY CLEAKUP�WATM QUALITY^HW PIPELME INV95TW.An0N�LO <br /> F <br /> FACam109 Isty, ACCOUNTID FRWROR <br /> � ."1 .fi}_':f,"rrr=i.tit, :Gt.• -,.?�. .,i <br /> FACILITYFME CONPLETETIfEFOLLOW1ArG BUSINESS]FACILITY/SITE INFoRAfA7w - <br /> Is this a NEw Business LocAmN riot pratrfousiy regulated by the ENORONNFNTAL HEALTH DEPARTMENT? YEs 0 No [ <br /> Is this an Ex"hin Sualnesa LocnnON but a NEW TYPE of regutated Business? Yes � No ❑ <br /> " ESSIFA LMISMNAW_ Blinco Trucking -- <br /> Sim A RM 2431 East Mariposa Road SUIMO 8=NE33 PHONE <br /> 466-9001 <br /> Stockton SCA z" 95205 <br /> (30ARD 4F$tlrolVtttOR DIYiRtCt L4Gh7fOPt COOS Keri FCtY2 <br /> Mating Ae a Jl0/FFERENrfiwrr FialilyAddnsaa Attantlom or Cara Of(opllaar!) <br /> Nailing Adttr*"City STATE zip <br /> SIC Cots APN R C°tllt£NT: <br /> THIRD PARTY lIKII-uma INFO. Complete X Billing Party is different from Property Owner or Facility Operator Idenv76ed above <br /> Rujiwm'NA"E Blinco Trucking Ationtiutr.orcareOf ro,ffkwm1l Gregg Smith <br /> MalfingAddr*U 2431 East Mariposa Road P"°"A 466-9001 <br /> stn Stockton sTATPCA zP 96205 <br /> for fwn and Charges 01WILEA FACIUTYIBUSINESS THIRD PARTY BILLING <br /> Htt t.Ce A.'m CO►RLrANCY Anavawitnettftxr: 1,the nadertfp*d aDV�ni;certify that[am the Owno,Opontoh 0r,�rahor$td,iStM of ltln Buaidesl,and T aeimar[edGt thH all PdwdrFass, <br /> IC/etrns E+�ox�nTGurce�andlor)10t'UY0,fAA 0 aaaoetated Witt WA operation wrillbe h9W tb me.c tLe.ddrnl[deytL(Ted above es rfx(caotTT�nneers for this site_J alrovcr*that all <br /> ird'a �ion pravlded on thh applkadoa h M*lad cnrreck and that all"pdatca actl�wta Hitt bt pef&rmtd In dceordaoa witb aL applitaaie SAK 36AQUlri COUM-Y 0rdtiu0ee C:.dm mN.r <br /> Sand2rdt.ed STATr and/or FEDMAL Lows%kW AcgnWom. Aa Me aOdtfdPtd o+raer,operma,or ik*nt aC th-property toratd at the¢4--fullftyhl4=ddi'eu,1 h mby—Ibvka the Telae or <br /> any end A rotdb and en�rro00iennt aarnment inf.ryud.4 f.SAN JOAQUIN COtJNW ENMONMExtALL 1UEALT"DEPAR1MENT a 1004 m it a avallabte ant at the Tome d—it it <br /> p-vtded w me Pr my RDn3tntadw- <br /> APPLICANTNAME(PLEmF.PtmtT) t5 its.-� �� siMATURE <br /> TITLE TAX ID# <br /> • 44 - a,S17Y7L <br /> 8y Osie A—&—ting Oft.PrOampl.t.d Ay D.t. <br /> STYE mmcckna+ a: <br /> Antx/ott•PAL° DAkt'tt OF PAYM7:4T PAYaIlNY TYPE RECEIPT, CHECK, RECENID A7 �'p` <br />