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Arv-wG- <br /> San <br /> J�quin County Environmental Health"artment <br /> a » ULj GREEN FORM c <br /> DATE 04 October:2:0 12 MASTER FILE RECORD INFORMATION MFR N-VgWO &LOP <br /> s ERtD# CASE# (3 fs IV <br /> ituanFn awvAB FOR EH U EONLY OWN LJ <br /> -- CNEcKw OWNER CjjmFMLyomnLEw11N EHO - <br /> I OWNER FILE:l 0NpLETE 7HEFOLLOW/N(3 PROPERTY OWNER INF0RAfAR0N.' <br /> PROPEM OWNER NAME Tarditi Rentals.PTP (209)931-6000 <br /> PHONENUMBER <br /> - <br /> First Ml Last <br /> - EIIMIL AODREss <br />` 18-INEWN—E T & T Trucking <br /> owner Home Address 11396 N. Hwy 99 <br /> $TATE ZIP <br /> cut Lodi Cq 95240 <br /> thvrnerMal"Am— as above <br /> Mele"��CRY as above sty " <br /> CORPORATnoN❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER <br /> SITE Mn1GATION_E"RONmENTAL ASSESSMENT_VOLUNTARY CLEANuE_WATER QUALITY_HW PIPELINE IN1!Wn ATION_LOP <br /> 6 <br /> FACILITY IO# INV# ACCOU SID(. .PR#I O I ASSIGNED EMPLOYEEFLE-A.AGENCY:EHD—RWQCB14—DTSC„_EPA_ <br /> It FACILITY FILTH COAlPLEM THEFOLLOW/NQ BUSINESS/FACILITY/SITE INFORAfA770N.- 1 <br /> Is this a NEW Business LoCAMON not previously regulated by the ENWRONINENTAL HEALTH DEPARTMENT? YES ❑ No 91 <br /> Is this an EMSTING Business LocATtON beta NEW TYPE of regulated Business? YES ❑ No <br /> CKI <br /> BUMN6BIFACILITYISITEN-E T & T Trucking <br /> &m AODRess SurtE# BUSINEss PHONE <br /> as above <br /> Coy STATE ZIP <br /> 1 <br /> BOARO OF SUPERVISOR DISTRICT UwATION CODE KtY1- K-=2 <br /> Malting Address IfOIFFEROfffYmrn F801AWAddrww Attention:arcate Of(t:pvdb W0 <br /> Mailing Address City STATE ZIP <br /> t <br /> SICCODE AEN I CvMMENr: <br /> C)Scf- Z4v �� i! <br /> + THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFacility Operator identified above. <br /> I BuslNmNAME Tarditi Rentals PTP Atientlow orCare Of(opMwW <br /> IYtalthngAddl"m 11396 N Hwy 99 PHONE 209-931-6000 <br /> CITY Lodi STATE CA ZIP <br /> for fees and charges OWNER FActuTYiBusiNESS X THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: [,the undersigned Applicant,certify that I am the lhvner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENAL77ES,ENFORCEMENT CHARCES andler 110um.rCHARCEs associated with this operation wit]be billed tome at the address identified above as the AcrouNrAlyl) s for this site. I 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 COUNTY Ordinance Codes 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,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN soon +s vailable and at the same time it is <br /> provided to me or my representative. <br /> APPLICANTNAME(PLEASETITLEPRINr) Terry Tarditi SroNATUR <br /> fi TAX ID# . <br /> Approved By Oats Accounting Office Prooesaing Completed By Oata <br /> SITE MITIGATION AMOUNT PAID DATEOFPAYMENT PAYMENTTYPE RECEIPT# CHECK RECEIVED BY WORK PLAN PE <br /> Z< <br /> FEE:# 3S <br /> i v <br />