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a Ua ll Couti E Ira,• ealtnj - . ce mronme� i. Dtvisib <br /> � <br /> DATE MASTER FILE RECORD INFORMATION FORT fEH oo 15(REvnED DTr23f97) <br /> sm r ep AREM FOR EMD UIF ONLY NIT IV <br /> OWNER FILE .Iv, - - ' -j <br /> COM_PLETETHEFOLLOW/NGBUSINESS OWNER INFORMATION.' CHECKIF OWNER.00TRENTLrONFILE*n,wEHD <br /> BUSINESS Sheldon Heckman PHONE 209 <br /> OWNER NAME =----------------=---=-------------------- 952-1675 <br /> AIM <br /> BuslNEss NAME(rf different from Owner Name) SOC SEC I TAx ID tf <br /> OWNER HOME ADDRESS 2346 Sheridan Way <br /> DRIVER'S UCENSE# <br /> ciw Stockton sTATECA zip 95207 <br /> OWNER MAILINGADORESS (if DIFFERENT from Owner Address) Attention:or Care of (optional) <br /> `'�r�e7•eTr�ee�r�a� <br /> Mailing Address City 2211 North Wilson Way State CA ' Zip 95205 <br /> CORPORATIONXX INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> •� . <br /> Facl tD` CROSS: 1l) e=AccboN Dlal ff r. r <br /> COMPLE7-E7HEFoLLowiNG 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 F,osnNG Business LocanoN but a NEW TYPE of regulated Business? YES ] No ❑ <br /> BUSINESSfFACILITY/$ITENAME Former Connell Motor Truck <br /> SfTEADDRESS 2211 North Wilson Way SUrrE# BUSINESS PHONE <br /> :209 466-2411 <br /> CITY Stockton STATE CA zIP 95205 <br /> .;=.::ir:�'•?;�.'S�G�-'3i::- ',i„ `r�.:�L- .�-�•5::'•� ��w""".. �`'a .� •:e.:t,; �,h,,,�y,::il:. �.,., <br /> Mailing Address ifDIFFERENTfrom Facility Address Attention:or Care Of(optional) <br /> same <br /> Mailing Address City STATE ZIP <br /> ItsiczabCOMM .. <br /> THIRD PARTY BILLING INFORMATION: Complete ff Billing Party is different from Business Owner Identified above. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> Mailing Address ? PHONE <br /> CITY STATE zip <br /> ACCOU)nADDRESS for fees and charges OWNER FACluTY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: L the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agew of this Business,and I acknowledge that all <br /> PERMIT FEES,PENALTIES,ENFORCEMENT C?LtRGES and/or HounrCHARGET associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRM <br /> for this site. I also certify that all information provided on this appikation is true and correct:and that all regulated activities will be performed in accordance with all applicable SAN <br /> JOAQUIN 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. I 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 /> /� r // DRIVER'S LEN <br /> ICSE# <br /> TITLE „-G,Sj C�L� lowmnmw wcdnoFnl <br /> 't'rocessirtQ' a <br />