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I'L ly-laal a:ZaPM FROM <br /> P- 2 <br /> DATE 12-23-97 MASTER FILE RECORD INFORMATION rt FR" GREEN FORM <br /> s,.Aaao MSAs fou END.Se OMPi ..• 'T- d —TA <br /> UNIT IV <br /> /f/���t OWNER FILE <br /> COMPlBTE E'FOLLOWINOPROPERTY OWNER INFORMATION CnEc fF OWNER CURRrNn roti Fttr ,THEHC) <br /> PROPERTY SAN JOAQUIN DEPT. OF PUBLIC WORKS PHONE <br /> OVrNtR NAME COUNTY (209) 468-3022. <br /> iter as <br /> aE <br /> BYSINESS NAYE PUBLIC WORKS SOC SEC/TAX IDM <br /> Owner Home Address 1810 EAST HAZELTON AVE, DRIVER'sLICENSE# <br /> Citi STOCKTON STATE CA <br /> ZIP 95205 <br /> Owner Yeilirp AaOrcaa <br /> POST OFFICE BOX 1810 _ <br /> Mailing Address City STOCKTON State <br /> CA Zia 95201 <br /> CORPORATION INDIVIDUAL PARTNERSHIP <br /> pED AGENCY OTHER <br /> 7 FACILITY FILE <br /> :FACILtn!fD^#t�� wuM <br /> COMPLETE THE FOLLOWING BUSINESS/FACILITY/SITE INFORMATION; <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DlNetpN? <br /> YES (3 No <br /> 0 No <br /> Is this an EXLsfING Business LOCATION but a NEW TYPE of regulated Business? YesBUSINE33/FAC1LftY/SITENAME COUNTY RIGHT OF WAY <br /> SITE ADDRESS INTERSECTION OF <br /> THORNTON ROAD AND WALNUT GROVE ROAD SUITE# BUSINESS PHONE <br /> Cm <br /> THORNTON STATE CA 7jp 95686 <br /> y�t1f16�'t'•t'- .�y �v + Y• 'ST�'rr -r--. t -:.. <br /> a_ � ..:ELrTM.'F+ l <br /> Mailing Address KO/FFERENT from Faelli[yAddress N/A Attention or Care of(oprionalJ — <br /> Mailing Address City <br /> STATE Zip <br /> n,' <br /> THIRD PARTY BILLING INFO: Complete if Billing Party <br /> is different from property OwnerorFacility,Operator Ident/fredsbove. <br /> BUStNES4 HANE COMMUNITY DEVELOPMENT DEPT Attention Or Care of (optional) <br /> JON MOORE <br /> Mailing Address 1810 EAST HAZELTON AVE. PHONE <br /> (209) 468-3065 <br /> Cm <br /> STOCKTON STATE CA zip 95205 <br /> ACCOUNFADDRESS for fees and charges OWNER FACILfTYBusmess THIRD PARTY BILLING X <br /> BILLING AND f.OTIr11Vif:C ACTCNOwLEDG--W- 1,the underaiped Applicant.certify that I am the Owner,()pl ,,or AYtho r:d oat of this Burin <br /> Ai' e8a.and I ackoowlalgc that Al <br /> PF.tAltr Fe+Lr,pcN,rine:',FJIFOeGEar/�vr CttAacET fnd/or FtVURLTCHaAY.'ft arblCwted wiW this Dpfradn0 will]re biltcd tow at ibe nddroT idcndried above"the Ar.TOCT7 MDlU:lT <br /> for this site. i sho ccrtifv that all intnrmutlon provided nn thea apPiictlou IS tr,.c and correct;and that all regulated acu%ifin,wTtl be performed in accoMance the aD VIWT DDSAT <br /> JOAQM CODhTV OrdlnnnR Code;and/or Staodards And STATE and/or FEDMAL 1.2 and RMn19fi0n5. ,V the undervlEaNd ojmv,oprnnm ors me ofthe rro <br /> above Facrlity/site address, 1 hereby authorize dse refuse or an and all results and mAmammul g I !Rrt!'bated al the <br /> Y aEsetamenI information�to N.IOAQL'IN COUNTY ENVIRONMENTAL <br /> IIFACFH DfRTS1ON m soon as it is available and at the same Gme it u provided to me or my repraentatbe <br /> / �� PLEASE PRINT <br /> APPLICANT NAME Law SIGNATURE s <br /> TITLE _ � `n-'f'�"-","—/ DRIVER'S CENS N/A <br /> 1 <br /> ,u. .Data . :",.'{i ]. i 'a.'f,i' ACc6linting OK{Oa�Ptoceasing'COmp etod8y�:'.: a• <br />