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0 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SivivEv SEcTvivs FOR EHD UsE ONLY OWNERIDB OASe>Y <br /> OWNER FILE <br /> CCMPLBTB mBFOLLCW/NaBu81 NEBB OWNER INFCRmAnCN., CHeoN/F OWNER CumeAlLYDNATLf likil <br /> BUSINESS PHONE: p <br /> OWNER'S NAME Fis/ ea Lar/ 212.Qa .[VL9 <br /> BuBINEss NAME(if de~of;;n 0vawrNains) sou sescvTax lOs <br /> <ecitt? -mcchOVILI InC. 36 — .3`9-2 60 <br /> OWNER'S HOME ADORE <br /> CITY STATE zip <br /> OWNPA's MAMJNOADDREas(if difterom fmmowmesAddrsss) Ada dbn arcare of <br /> 5(05 Ave- - aur t1Floor <br /> MAILINo ADDRESS CITY 1 ��. OYk- TA Szip 6 <br /> 0 <br /> !J 7 <br /> TYra ovOmwlnrrr: <br /> CoormAtrialf,0 limomfolmi.❑ PAIR mNIF❑ LooALAIIENOY❑ CotAmAa WY❑ erATEAQVWr—J FEDA00WO OMPA❑ <br /> FACILITY FILE <br /> FACILIrY ID N: CG-OWNER IDN: ACCOUNT ID M <br /> Comm wFoLLowfNa BUSINESS FACIUTY/NfORA Anow., Ly' <br /> Is this a NeW8uskwse LOGATM or VEWal notprevkusly regulated by the ENVIRON ENTAL HPALTH DEPARTNENT? YES ❑ No rte, <br /> In this an FAInNo 6lrekwss LOGATION but a New TYPE of rogulatad Susktess? YES [] No <br /> BUSINesWAccmNAME(Thiswillbotheacsae AUmo.,ilioWALTHPMMrf) <br /> OWhcY ea-Y-vl <br /> FACIIJTYAotiftss(NPA jsa MoarzaFao (/N/rarFoaO V<Ix[auw the CoMMIna+RYADMEM BUSINESS PHONE <br /> lro24East A��inc Avg • sasaa ZI?-•Q%rs. 1o29 <br /> CITY(IIFAUUrvlso MMWPWo UNITor Foos VO,x usolho Cf .MissN Crrv) STATE TIP 5 <br /> BRooPBtweAvisoa DlarwoT LOcAroNl COoe KEYi KEY2 <br /> OA <br /> M/aUNOADOReell/OPHooOPB/n1H(I/O/FFERENTfrom Fac/L/lyAddr000) AEulwwn uc.r.a <br /> LA-e*- o rcl s Csfe��o NIM tike <br /> MAILING ADDRESS CITY G h n i S STATE GA zip 9 2024 <br /> SIC Coac: APHR Corarnr: <br /> / CQQUIYTAQOREW for fess and charges: OWNER FACILITY/BUSINESS El <br /> BILLING AND COMRIANCE ACNNOWLEDOWNT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Auffmrizod Agent of this Business,and I <br /> acknowladge that all PERMIT FEES,PENALTIES,ENFORCEMENT CNAnces and/or HOURLY CNARors associated with this operation will be billed to me at the <br /> address Identified above as the Acc"rAoaness for this elle. I also certify that all Information provided on this application Is true and correct;and that all <br /> regulated activities will be performed In accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes Sadler Standards and STATE andfor FEDERAL <br /> Laws and Regulations, / .,/ <br /> APPLIOAwls NAME: )G� l 'f t7/Jli/ �!?Gr SIGNATURE; J/' !� <br /> �/ �P/aa aPNnf ORIvait aIJaLI ENeEY ' <br /> Timm y,c e r�S�4c�/1 GATE ,2/> / <br /> Approved By Dale Accounting Office ProaaaNng Complalad By oats <br /> A PROORM(EHD 48-02.-034 Pink)or WATER SYsTEw(EHD 48-02-003)form miait be amplated for DAch EHD regulated operation at this LOCATIOt1 <br /> except UST Program(Use SWRCB forma) <br /> EI-1040-02-035 MeatartlIS Racord Groon <br /> 11/27107 <br />