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ORIGINAL <br /> San Joaquin County Environmental Health Department <br /> DATE 3/15/04 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SNAnm AA...mo . <br /> Fun,Knav OWNER ID# a01�- .� CASE# UNIT IV <br /> OWNER FILE <br /> COMPLE7F 771E FOLLOWING PROPE RTY OWNER INFORMATION: 012yIF OWNER CURREAULYONntewmi EHD <br /> PROPERII(OVANER NAME Russell Ka ehiro PONE 209-835-9491 <br /> Fbst MI Last <br /> BUSINESSNAME Jepsen Webb Ranch LLC SOCSEC/TAXID# <br /> Owner Home Address 7200 W. 11th Street DRIVER'S LICENSE# <br /> City Tracy CA zm 95377 <br /> Owner Mailing Address <br /> Same <br /> Mailing Address City Same State zip <br /> rwvnpooaaeeeara A� <br /> CORPORATION❑ INDIVIDUAll1AV> <br /> PARTNERSHIP EJ Fro AGENCY❑ OTHER 11 <br /> FACILITY FILE <br /> FACILITYIDAt �O/5at�.( CROSS REF ID# ACCoeNTIDAt 141 INV# <br /> MPL 7HEFOLLOW 1VG BUSINESS I FACILITY SITE INFORMA770N., 3 <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO <br /> Is this an EXISTING Business LOCATION t NN!V DPE g r gU ated Business? YES ❑ NO ISI <br /> BUSINESS/FACILRY/SDE NAME Lf O �^ OLl .// II <br /> SCTEADDRgsAPN 209-240 -26,27. 115 Acre 0'W. of Valpico Rd/ ammerss.Ufry SINESSPHONE N/A <br /> N/A APN 209-240 -30. _ 5 Acre 5000'W of Val ico Rd Lammers Ferry Rd <br /> CITY Tracy STATE CA 'p 93577 <br /> BOARDOFSUPERVSORDIsmicr LoCnoN CODE KEYS KEY2 <br /> Mailing Address NDIFFERENTfrom FacifityAddress Attention:or Care Of(optional) <br /> 7200 W. 11th Street <br /> Mailing Address City Tracy CA STATE zip <br /> 7 <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party /s different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:or Cam Of (optionalf <br /> Kennedy/Jenks Consultants Mike McLeod <br /> Mailing Address PHONE <br /> 622 Folsom Street �1� 415-243-2150 <br /> crr San Francisco STATE CA zip 94107 <br /> for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILIaNC,AN COMEIIANPPAr NOW1.EW,MF,N'r: I,the undersigned Applicant certify,than am the Owner,Operamq or Authorized Agent of this Roll ns,andladuwwl tall FRaanrFM, <br /> )`FNdLTl84,FNFORCEl1 CH5 ni=.ndlor H0MYC1btRm'associated with this operation will he billed to me at the address identified above as the or this site. I also carfifythat <br /> all Information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable S4 JOAQmN COumv Ordinance Codes and/or <br /> Standards and STATE and/or MEHAL Laws and Regulations As the undersigned owner,operator,or agent of the property,Incited 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 DEPAR NT as soon as H is a lable�and at the <br /> same time it is <br /> provided to me or my representative. <br /> /� // n � `✓`ice <br /> PLEASE PRINT Y��f/1(/f// <br /> APPLICANT NAME Michael L. McLeod for Musco Family OliV eCOSIGNATURE <br /> TITLE DRIVER'S LICENSE# <br /> Geologist (PHOTOCOPY REQUIRED) <br /> Approved BY Date Accounting Office Proressing Completed By Date V <br /> 29-02-002 April 25,2003 is <br /> • <br />