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U'L/10/Znll 1Z:nf mwovoa as urv.nu.•u. ,-� ..- ^�� "' <br /> SAN JOAQUIN GOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> r ERFILE RECORD INFORMATION ForAP <br /> SMMSEURONSFOREHDUSEOIar -,$ r _ r ,, w Jx <br /> OWNER FILE <br /> COMPLETE THE FOLLOwrNGBusENESS OWNER INFORMATION: CHEM 1F OWNER 4a4WNILYOx frLE wnN ENDQ <br /> BUSINESSSVVt\ PHONE: Q�( <br /> OWNER'S NAME fr:r AH (eat Zo l—�u�S1 —�W <br /> BDSlI'1E55 NAME(If,IMbenr Ad.Owner rtarrw W Soe Sec o,TaR ID A <br /> 1-7—IJ-D9 133 <br /> OWNER'S HOME ADDRESS <br /> CITY ST Zip <br /> OWNER'S MARTNG ADDRESS(B drrrteEM*pMOwner`s AddnMS) ACC1rtl.e.rpre or <br /> CITY S <br /> MAILING ADDRESS TATE ZIP 10 201, <br /> TYPEWOWNEIISIQUIR: rr-'�� omc JoII Aaui/ cnl <br /> CORPOIIATION❑ INDIWDUAL PARIwERSHIPt] LOGLLAGNCY❑ COVNRA44NLY❑ STATE AGENCY❑ FED AGENCY Ry <br /> yFACILITY FILE <br /> "�ACIU � ^ .N"''"': .,. ..¢�,;,` v>Yt� ^r�s""A '�%; :',�•, �'/,'r 'e,� <br /> COMPLETE rNEFOLLOWINGSUSINESS FACTLTTY INFORMATION: <br /> Is this a NEW SusineSS LOCATIDN or t wnxE not preelously regulated try the ENVICRONMENTAL HEALTH DEPARTMENT? YES U NO <br /> I5 th6 an M51IN6 Business LOCA71oN but a New TYPE of regulated Buslnesst Yes ❑ No x <br /> BuSENESS/FAC1UW NAME(TN5 01 be the ffa4AES Mww tae NFALTH PERMIT) <br /> IVC Gra W n <br /> FACILITY ADDRESS if fAMY a fixe.tArir«GOOD t'Hm<ase McCMMi•.Mr"Iti;%) BuStNESs PNorm <br /> ZULBy �AOo t't^t-( 1L1L swea <br /> CITY(NFAwrraa M. .fb..UMrar Fo..VErn7t aae theON101011AtyLTr1) STATE ZIP <br /> CIS <br /> a.\ l <br /> V �?t• �wn�.:t_�: -M�,� L e' ,'aCxE s'T{. <br /> MA1Lv.c ADDaEss for Hearth Per4wtpf o/fl Ran-rree rmRyAd*r ) AtwdieR. Cars Of <br /> MAILING ADDRESS CITY STATE ZIP <br /> �c� .r': yykyt� r %3'" .y- '''.^i:-.' ,sYr c a t � :-.E•t� °, v '„. .: .. i_ _-r� ' .kzkc,7•` T e''NE <br /> '. <br /> , 'v+..4 -'' �i'i<, rr, >:r ?Y ..f^� .:r!'mr A f'1._Y; t f.,�+ , a•:. al. <br /> ACIrouNrA W,&M for fees and charges: OWNER ❑ FACILITY/BUSINESS [� <br /> BILLNG AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that Ism the OWnee.Operator,or Aufhorfred Ant d MIS BUStI1ess,and <br /> I acknowledge that all PERAEr Firs,PENALrM,ExFONDEMENT CNARCES endJ«HWm.1'CHARGES assoclatetl with this Opara11 p be biliad lO rrle ai the <br /> address Identified above as the ACcmNrADDRESs for this she. I also certify that all Irdorroation prwlded On this licati is ue aril correct;and that <br /> all regulated activities will be performed in accordance with all applicable SAN JO <br /> AOIIM CWNTY Ordirgnce d a ! 3 ndartls and STATE anNor <br /> FEDERAL Laws and Itagulatiom. - <br /> ApmcANrs NAME: Z-Y- SIGNATURE: <br /> MFla <br /> TITLE: DATE DRmR'S rPr RE E act <br /> OcoPrR IaRED <br /> A PROOMN (EMD 48-02-034 Pink) « WATER SYsrEAr (END AA-02-003)- form must he CmnPletrd tor each EMD regulatadeparation at this <br /> LOCATION except UST Program(Use SWRCB f«mS) <br /> MW 48-07-D3% Ma,bMle Record-GA n <br /> wiww <br />