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San Aquin County Environmental Health *artment <br /> DATE GREEN FORM <br /> MASTER FILE RECORD INFORMATION "MFR" <br /> CuenFn ARFec Fog FHn uaF nNi v OWNER ID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION CHECK IF OWNER CURRENTLY ON FILE WITH EHD ❑ <br /> PROPERTY OWNER NAME <br /> PHONE 209-538-3131 <br /> First M/ Last <br /> BUSINESS NAME <br /> Barrel Ten Quarter Circle Land Co. SOC SEC/TAxID# <br /> Owner Home Address DRIVER'S LICENSE# <br /> City <br /> STATE ZIP <br /> Owner Mailing Address 6342 B strum Road <br /> Mailing Address City Ceres State CA ZIP 95307 <br /> IPF/1F nWNFDG{JTD <br /> CORPORATION Ix INDMDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID# E <br /> ACCOUNT ID# INV# <br /> COMPLETE THE FOLLOWING BUSINESSI FACILITY1 SITE INFORMATION.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FACILITY/SITE NAME Barrel T e n <br /> Quarter Circle Escalon Winer <br /> SITE ADDRESS 21801 Highway 120 SUITE# BUSINESS PHONE <br /> CITY Escalon <br /> STATE CA zip 95320 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYS KEYZ <br /> Mailing Address ifDIFFERENTfrom Facility Address Attention:or Care Or(optional) <br /> Same Paul Franzia <br /> Mailing Address City STATE zip <br /> SIC CODE 11 <br /> APN# F <br /> MENi: <br /> THIRD PARTY BILLING INFO: Completeif Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> Kennedy/Jenks Consultants Mike McLeod <br /> Mailing Address PHONE <br /> 622 Folsom St. <br /> 415-24-3-2150 <br /> CITY San Francisco STATE CA ZIP 94107 <br /> 4 ccouNTAnnoccc for fees and charges <br /> OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Hill INC %Nn f'QMPljANCF ACKNOwI FnfMlll' 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERsin FEES, <br /> PEA'IIC//FS,HNFOR('FDIFNTCHAHGF.1'aotilar HOURLY(HARGES associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRFSs 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 COt1NTY Ordinance Colles 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 HEALTH DEPART I T as soon as itis <br /> available and at the same time it is <br /> provided to me my representative <br /> N <br /> APPLICANT NAME Mike McLeod P,G. PLEASE PRINT <br /> SIGNATURE <br /> TITLE Geologist DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIRED) <br /> Approved By Date Accounting Office Processing Completed By Date <br /> 29-02-002 Apti125.2003 <br />