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wISI�LSU v LL.L�I <br /> San Joaquin County Environmental Health D•rtmAV 1 7 2006 <br /> DATE I c- -lit✓ MASTER FILE RECORD INFORMATION "MFR"ENVIRONMEffMPR"' <br /> RMIT/SERVICES <br /> nr can UIF nu,v OWNER ID# 13 'S CASE# UNIT IV <br /> OWNER FILE <br /> �A COMPLETE?HEFOLLOWINGPROPERTY OWNER INFORMATION; Gf .ne OWNER CURRENTLYONRLEWITN EHD <br /> Ytl n A <br /> PROPERTYOWNER NAME �M� T �fvl LSc%4 aEIbE''P- PI1IXiE Z0ej- L{66 - 11y63 <br /> First MI I Last <br /> BusaNESSNAME V t N elf- Q0 C— w t N 6 Ce,LutaS S0CSEC/TAXID# <br /> Owner Horne Address DRIVER'S LICENSE At <br /> CRY STATE ZIP <br /> Owner Mailing Address <br /> Mailing Address City / 7\F OQ � zip <br /> Tvor rs.nWNFRgMso 7 d' O <br /> CORPOPATION❑ INDIVIDUALIyy--�TM PARTNEASHID❑ FEDAGENCy❑ OTHER❑ <br /> FACILITY FILE <br /> FACDSTY ID# ly( )31 CROSS REF ID At ACCOUNTID# - -rINV# <br /> uV N\O N N' ` o <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BusxNE55/FAasrY/SITE NAME V L N O T C)E QJ E W t IJ E CE LL A4.5 <br /> SITE ADpREss SUITE# BUSINESS PHONE <br /> l"1�v8 EsFST qL-PI.�E AVE r.1v.� �j CIT ['- <br /> S!(-�C.Y��"'h fit "'CA, ' 1SZAJ <br /> Qn <br /> BoARO OF SUPERVLSEXt DISTRICr LOCATION CODE KVI KEY2 v <br /> I\� <br /> Mailing Address if DIR TRENT fmm FacffityAddms Attention:w Care Of(opbbm1) 1 , <br /> Mailing Address City STATE ZIP <br /> SIC CODEoo^5.f.Z_� APN# 117 V8JC� COMMENr: <br /> THIRD PARTY BILLING IN-,-) <br /> Completeif Billing Party is different from Property Owner or Facility Operator identified above. G <br /> BUSDtess NAME Attention:wCare Of (trpubw <br /> T l) <br /> v <br /> ( b4RA"r-A CAD"SotarA " T'N C- O o G-, —3 , <br /> Mailing Address 'l'i01 "L„ i,-f,- j?-b, $ j -r& L'/S-0 PHONE Gl(6-'7ffy—Z2.�• �j (�� <br /> Cm ,�D5��1t1E STATEnAT zTP q�.7g \'6 <br /> AccmwrRawo for fees and charges OWNER FACILITY/BUSINESS `+ THIRD PARTY/BILLING <br /> Rt NG AND CnMpz.TANcc AckNow cnr.MEUT; L the undersigned Appheam,certify that I am We Owner,Opem0or,or Authorized Agent of this Business,And I acknowledge that an PERMIT FEES, <br /> PENN ITEC,ENFOR6 lVTCHMGES and/ar HOVRLYCHd GES associated with this operation will be bitted to meat the address identified above As the 4tx01JNT AnnReec for this sift. 1 also cerfify that <br /> all information provided on this application is nue 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 envirommeotal assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as '15 av ' le and �me§rile it is <br /> provided to me or my representative. <br /> �` PIFASE RUNT <br /> APPLICANT NAME SIGNATURE M t c HgEL ��ArgC A-46� <br /> TIRE /�� tL r� /� ..! DRIVER'S LICENSE# <br /> �J kfty-Mrsw(A L- GleDL06kS1 (PHOTOCOPY REQUIRED) <br /> Approved By G- pale f Accounting Office processing Completed By Date O <br /> 29-02-002 Apn125.2003 <br />