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U4121/2004 22:38 2098306837 CITY OF TRACY FIRE PAGE 01/01 <br /> 5-rkVR! 5*14 SAN JOAQIKI COUNTY ENVIRONMENTAL HEALTH DEPP-rdMENT r �''cecs— <br /> _373 MASTERFILE RECORD INFORMATION FORM 4?, 5 D 3 <br /> SNAom SECTIONS roREHD USE ONLY OWNER ID# ,CASE# <br /> OWNER FILE <br /> COMPLETETHEEVLL WING USINESS OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FRP WTH EHD <br /> BUSINESSPHONE <br /> VL�4i/.¢i41 J ��' `� ? �•r . f <br /> OWNERNAME <br /> Flraf Mr Last 20? <br /> BUSNMNAME Qrdmbrwrca�Owner Noire) / SocSecorTaxlD# <br /> OWNER HOME ADDRESS �� /l y� /i <br /> CRY VrIN �'Ii�� / I1.�cG C4 $TATE ZIP �C'3 <br /> OWNER MAILING ADDRESS(Ir df"tacm OWner Address) Attention or Care of <br /> MAILINOADDRESSCRY STATE ZIP <br /> TYPE OF OWNERSHIP: <br /> CORPORATION INDMOUAL❑ PARTNERSHIP LOCAL AGBICY❑ Cp1MYAOEIVI ll STATE AGENCY❑ FEDAQF"c'Y❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID#: Co-OWNERID#: ACCOUNT ID#: <br /> COMPLETE THE FOLLOLWNG BUNINFSS FAQ161a FAQINFORMATION: <br /> Is IRAs a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DE➢ARTNEN? YES ❑ No ❑ <br /> Is this an Da3rm Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ II <br /> Buwjm;s/FACKM NAME CThL%vAll he thesusREsaNiwon the HEALTH FEYMIT) <br /> i <br /> FAaLrrYADDRESS(IfFA(MYISOMO&4EFOoo UMTorF000t'E}UUSetheW &MRL&9 BUS1NE38 PHONE <br /> I <br /> sues# <br /> C <br /> itysa Ajm"Mcharges: <br /> rtYEuse the Roaisamax d =E] FACLMISUSINESS <br /> ZIP <br /> SUPERVISOR LOCATION CODE EY2 <br /> a3 thr DFFERENTfmm Facj'VMOP" <br /> I <br /> ESS CITzip <br /> :A02Rd Charges: INESS ❑ <br /> BffjJNQ AND O IAS A Kb rDrtttxxrt r, the undersigned Applicant, certify that I am the Owner, Operator, or Anthor4:ed Agent of this <br /> Easiness,and I acknowledge that all PER,ulTFEF3,PENATTIFS,ENFORCE.WFNTCHARGES and/or HOMMYCHARGES associated with this operation will <br /> he billed to me at the address identified almve as the ALCORRF Annnzse for this site. I also certify that all information provided on this <br /> application Is true and correct; and that all regulated activities will be performed in accordance with all applicable SAH JOAQmv COUNn <br /> rd1mmceCocjcsAtdjorStandaKjj,. PATER EDERAt. and Re <br /> PPL AME• IGNATURE' <br /> Please pmr <br /> Trn-E: DATE DRNER'S LICrNSE# <br /> (PH Oan�Rscujg= <br /> ���9y p� AccouMin9 Offlce Processing CompletM By Date <br /> L_ <br /> A PROGRAM(EHD 48-02-034 Pink)or WATER SYSTIN(EHD 16-02-0031 form must be completed for rAch EHD regulated operation at this t 012-ATION excep <br /> UST Program(Use S WRCB forms) <br />