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Sa' ouiriCoun IrG : ealtFrSewicenvrroalmen~ '� ealt''Divsior <br /> ' FORM (EN 00 1 6(ReviaED 07R3l97) <br /> DATE ASTER FILE RECORD INFORMATION <br /> SN�OED AREwb Fon EHD VSE ONwN7 � <br /> � R SNIT IV��� <br /> OWNER FILE <br /> COMPLETETHEFOLLOW/NG BUSINESS OWNER /NFORMAnom CHECKIF OWNER CURRENTLYoNFILEwrHEHD <br /> ........................................................................................................._.................7....................................................._._............................................................................................................... <br /> . <br /> BUSINESS Sheldon Heckman PHONE 209 <br /> OWNER NAME �---------------- ---- ---- 952-1675 <br /> .................................._................................Fix.---.--.................................NL......_..............._._..................eau..................._.................. <br /> ` <br /> BUSINESS NAME(If different from Owner Name) SOC SEC I TAx ID# <br /> a <br /> OWNER HOME ADDRESS 2346 Sheridan Way DRIVER'S LICENSE# <br /> city Stockton STATECA zip 95207 <br /> OWNER MAILING ADDRESS (if DIFFERENT from Owner Address) Attention:or Care of (optional) <br /> Mailing Address City 2211 North Wilson Way stateCA ' zip 95205 <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FAauTY ID# CRoss RE>ID# AccDUNT ID# NV <br /> COMPLETETHEFOLLOW/NG BUSINESS / FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ NO <br /> Is this an ExIsnNG Business LOCATION but a NEW TYPE of regulated Business? YES )�3 No ❑ <br /> BUSINESs/FACILITY/SITENAME Former Connell Motor Truck <br /> SITE ADDRESS 2211 North Wilson Way SUITE# BUSINESS PHONE <br /> :209 466-2411 <br /> CITY Stockton STATE CA ': zip 95205 <br /> Mailing Address ifOIFFERENTfrom Facility Address Attention: or Care Of(optional) <br /> same <br /> Mailing Address City '7 Or f -7 STATE zip <br /> SIC CODE 11'APN :. .Y.(; CoraMENr <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above. <br /> ............................................................................................................•---------------......--...------.----..------------............---•--.............................................................................................._.................... <br /> . <br /> BUSINESS NAME Attention: or Care Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> AccouNrADDREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all <br /> PERMIT FEES,PEvtLnFs,ENFORCEmENTCHARGES and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the ACCOUNT ADDRESS <br /> for this site. I also certify that all information provided on this application is true and correct:and that all regulated activities will be performed in accordance with all applicable SAN <br /> JOAQULN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the <br /> above facility/site address, 1 hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> PLEASE PRINT .� <br /> APPLICANT NAME � SIGNATURE <br /> TITLE <br /> DRIVER'S LICENSE# <br /> / 'l/rcS%�'cr<=�� (PHOTQcowRFonIRFn1 <br /> Apprvt+ed BY. ._„ ai OWn ca Processing Comp ted € Da <br /> /f Pz3 &l <br /> c � <br />