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M <br />San Joaquin County Environmental Health Department <br />DATE ° MASTER FILE RECORD INFORMATION "MM'S <br />a..._.._.DARat"Kiia"Quiazony OWNER We <br />tlna now re ./+mans n PatlC tArft r yxwmat] W <br />CASs#( f 0 93 5'D r,D <br />GREENFORM <br />SITE MmoAnoN & LOP <br />,..UNIT IV <br />N M EHD 54 <br />MIOFERiY OwNR tO= <br />Dont <br />Ila SGfL <br />(UT) S --ay - ?+Zo"t. <br />PAymawr TYPE RSCeoPr0 <br />Fust <br />Art Last <br />PiRMENUMNpt <br />twaNESSNA" EARrmCLAar.vs SAleflV . CO.rWlvy r/f/c, <br />&INALADD <br />PN lse a SL. 8(iUMAj1..ten4 <br />Owner Homs Address <br />?.(p$'i SouYt. Air •r7' 6(IG� <br />b► <br />city s r o c � rotv <br />Ca <br />�' s Zd c <br />A '/ <br />Owner Mating AWreas S ACHE Ax A &W <br />MW*%Ad, sORy <br />8Se4+ <br />zp <br />Mailing Address f/D%FFSTEW4-Pm FhrARyANldr*" Attention: o Cors Of (apillboad) <br />MaWng Addre.. City <br />STATS <br />CoffoaArmlt ( DIWOOL❑ PAarNERsHP❑ FED AWNcr❑ OTHER❑ <br />Sm LrlTIOATION _ ENviai"=0STAL Asemai@Ni _ VOLYfrrany CLBARW _ WATNt GuAuTY _ NW Pim INVgINTIGATIM _ LOP <br />PACILIW 100 <br />two ACCOUNTID PRNROi <br />34?410 io R*-~oq <br />CAwnnyaSRn/anAapercnrrrn�/nwAra/3USIOdES3� <br />Is this a WIN Basirrass LocATHM not Previously regulatscl by the EwincomumAL W.ALTTI DEPARTMENT? <br />Is this an EXISTite Buslriess LOrATION but a New TYPE of regulated Business? <br />YES © <br />YES O <br />NO <br />No <br />BUMM SSFFAMUrrx" Naas &M L5 A f A 604 <br />PAymawr TYPE RSCeoPr0 <br />CHECK <br />Ertl A00REss <br />SuRai <br />suslNlq PH40M <br />Cm <br />aTATE <br />b► <br />SoAaaoFftiawtr40R0srlsar <br />Loc^rouCow <br />Kerr <br />Klv4 <br />Mailing Address f/D%FFSTEW4-Pm FhrARyANldr*" Attention: o Cors Of (apillboad) <br />MaWng Addre.. City <br />STATS <br />ZIP <br />BICCODe <br />APNi 3 <br />ZO O <br />fllCOHtty <br />' for fins and charges OWNER FACR.7iY/BumESs C THiRO PARTY BILLING I <br />BILLinG AND CO_W AK79 ACKNOwLEDGNiNr: i, dw mldHrip" Apptiae4 owes[)' Rtsl 1 = We Ot . OPeramr, or AnWritd Apat of IW Blains, ad I *dON vkd`e tail W PHAWr Ptas, <br />Pe "rrxL , EvPDacptrnr OuRGts Mdrof JJOURarCkAacm awdated with this "ad" %0 be biNsd b mat the address kdDflad above n Ise ACC20T.4 argils 1w dh site. I also ar1Nr Hut e0 <br />information pro Wed or, this appsados N Mtn Rod comet: and tM1 ae reptated auMdn cola be performed In acmadana with W SWIC'Sbk SAP JOAQUIN CDIARV Or6etaotte Coda an"r <br />Standards and STATE and/or FEDCRAL Laws and RtEWatkm. As the undentped scow, operalo , ar aydlt of tAe propnry located at Ihr On" ERCWryhiff address, I hereby autlmwtre the release of <br />any and W maib end asvf Mnul •esassoent iefonnatioa to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as N Is avallabk and u dM Same dine it Is <br />provided to me or my rep a ffl*dve- ?4-/ <br />,i <br />APPLICANT NAME (PLEASE PAINn r 4 t•. % <br />TAX IG # <br />TITLE prpT�� /L1a,a.rl�r a7 - 30 <br />ear Data Carla, Proaesl Goapttd2t Data <br />FETE NIFKIATIOM <br />AMOUNT PAtO <br />DATE OP PAYMENT <br />PAymawr TYPE RSCeoPr0 <br />CHECK <br />RedEtvCO [iT 'MJDRSI,PI:iW i' .... <br />F!C¢ <br />�Sa <br />