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San Juin CoLtnty Environmental Health 0artment <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR�� <br /> ,i nnFD eRFes FOR FHn USF ON'v OWNER ID# CASE#T-T UNIT IV <br /> OWNER FILE <br /> CHECK IF OWNER CURRENTLYON FILE WITH E H D ❑ <br /> COMPLETE THE FOL L0WINGPROPERTY OWNER INFORMATION; <br /> PROPERTY OWNER NAME PHONE 209-538-3131 <br /> First Ml Last <br /> SOC SEC/TAx ID# <br /> BUSINESS NAME <br /> Barrel Ten Quarter Circle Land Co. <br /> DRIVER'S LICENSE# <br /> Owner Home Address <br /> STATE zip <br /> city <br /> Owner Mailing Address 6342 B strum Road <br /> Mailing Address City Ceres State CA ZIP 95307 <br /> TYDF nF nWNFR1HTD <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER El <br /> FACILITY FILE <br /> FACILITY ID# <br /> CROSS REFID# ACCOUNT ID# INV# <br /> COMPLETE THE FOLLOWING BUSINESS I FACILIIY.1 SITE NFORMATION' <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NoI <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FACILITY/SITE NAME Barrel Ten Quarter Circle Escalon Winer <br /> SITE ADDRESS 21801 Highway 120 SUITE# BUSINESS PHONE <br /> CITYSTATE C^ ZIP 95320 <br /> Escalon /1 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE �7KEYl KEYZ <br /> Mailing Address WDIFFERENTfrom Facility Address Attention:or Care Of(optional) <br /> Same Paul Franzia <br /> STATE ZIP <br /> Mailing Address City <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> Attention:orCare Of (optional) <br /> BUSINESS NAME Kennedy/Jenks Consultants <br /> Mike McLeod <br /> PHONE <br /> Mailing Address — — <br /> 622 Folsom St. <br /> 2150 <br /> CITYSan Francisco rl STATE CA <br /> ZIP 94107 <br /> e= stir�.,�oF��for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Ru I INC AND CoNtT'I IANCE c CKNOwI FDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Ageet of this Business,and I acknowledge that all PERAnTFEES, <br /> PEA:4L,aEs,ENFORCEAfF,NT'CHARGE5'and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the 4CCOUNTADD2.S.F for this site. 1 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,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HFALTH DEPARTR,41INT as soon as it is available and at the same time itis <br /> provided to me or my representative. PLEASE PRINT <br /> APPLICANT NAME Mike McLeod P,G. SIGNATURE <br /> TITLE Geologist DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIRED) <br /> Approved By Date <br /> Accounting Office Processing Completed By Date <br /> 29-02-002 April 25,2003 <br />