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0 <br /> nay10 02 11 : 57a San Joaquin DES 209-468-2600 p.2 <br /> BUSINESS OWNERIOPERATOR IDENTIFICATION FORM SIDE t <br /> HFGLN'NINO DATE(1)[�� I. IDENTIFICATION (3)FAGE I OF1773 <br /> BUSINESS NAME (4) BUSINESS PHONE(5) <br /> C 11i.i FHr /31fK1 1 u9-y]y-gasY <br /> SI'L'L ADDRESS (6) D <br /> .S7S� P�FCG /f7/E" <br /> . IterI No Dietetic strect Nail a"gpe A nlRIdgNSui e <br /> CITY (7) STATE(S) ZIP(9) <br /> STa alp ra�1 649sz 07 <br /> UUN dr l(o) sic CODH 14 DIGIT#10 1) <br /> RRAWMRL'Er 197 Y7 607 <br /> OPERATOR (12) UPU:A TOR PHONh l i 31 <br /> NAME (?k VA2p< 7 2 <br /> 11. BUSINESS OWNER <br /> OWNER NAME t14) OWNLR PHONE!151 <br /> C3�C�n/,(;c� 1.,�nat.vr�in✓.tG- t <br /> OWNER ADDRESS (I6) <br /> (if differdw Ram Fntrtui 06or 041) UaZ <br /> CITYfl7) 214-GGASS1'A'PL•(IS> L7S'a <br /> ._.:I ZIP(19) Yo <br /> 111, IRONMENTAL CON'T'ACT _ <br /> CONTACT NAME(2U) CONTACT PHONE(2 1) y77 _2 SY <br /> CONTACT ADDRLSS 122) <br /> (IfdiffcrcntPron,C-nnic,wf, 3�� ❑ C yup 1^1 <br /> or 0411 Strecl NO 1)vsrion So cc Name Strew vo, A t.$B d•l�urtc•IS,�ure <br /> CITY(23) STATE f241 llk,(25) <br /> ,S7-NCKTD�I � 7S`2o9 <br /> primum IV. EMERG NCV CONTACTS Setevode <br /> NAME(20 NAME'(JI} <br /> TITLE(27) 'f11'1 A t 12) <br /> �t� 0/.eecx�rc ��✓r-�u�. ys��.r��,t <br /> BUSINESS PHONE(281 'T/6 ' 77/- 7 33`/ BLI,SINESS PHONE(331 Zop- �/7Y` zany. <br /> 24-HOUR PHONE(29124-IIOUR PHONE(34) - y 77 - ZSY7 <br /> (After Rum,..,Nnurvl //�^ �7/ 7 J S 3 (After eumrcas WOW 2,of <br /> PAGERF(301 PA13ER0(35) <br /> UY-HAZA <br /> ON-SITE ENS (36) QY£5 NO If yea,nod nbave Threshold Quanuuc..anaih a Steel at paper witl,a genenil <br /> description of the nxess and Principle e4oipm7 m <br /> AUDITIONAL LOCALLY COLLECTED INFORMATION(3'!1 Provide Infornmrinp rcyacv,ed un t1u hunk of lhly form <br /> NAM OF DOCUMENT PRF.PARER(38) - Clt' j <br /> NAME OFOWNER/OPP_RATOR(39) r-. DATE(4m OZ <br /> aitit�eaee r. 7n <br /> SIC. 12100 <br /> 70 39Vd 9EELTLL916 LS:60 Z00Z/ZT/S0 <br />