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Z__ <br /> San a' uin County Environmental Health 0-vartmentrqJUNGIAIPArll <br /> DATE ;.14 7 I;, MASTER FILE RECORD INFORMATION "MFR" �NVIRONMENTHEAJH <br /> UNHICl/ <br /> SjAnFn ARFGC FMl FHA IICF(INI Y OWNERID# �.,-ti <br /> OWNER FILE <br /> CHECxIF OWNER CURRENTLYON FILE WITH EHD <br /> COMpLETETHE FOLLOWING PROPERTY OWNER INFIpRMATION, _ <br /> PROPERTY OWNER NAME .� + t1�rJ PHONE ��f 7 <br /> '.3 <br /> 1 ..Y M/ Lost <br /> First <br /> SOC SEc T D#„ <br /> BUSINESSNAME ��\ \ �� <br /> o s w�-• <br /> C� <br /> DRIVER'S utENSE# <br /> D <br /> Owner Home Address G r e"C e— �+ , p <br /> 1 STATE /�:i z- 7-7 <br /> Ili <br /> Owner Mailing Address Is!7 L (Sr�� C'. <br /> / Zip C�J 77 <br /> Mailing Address City T <br /> TVeF 11F r1W mqm �o <br /> CI� <br /> PARTNERSHIP FED AGENCY <br /> CORPORATION INDIVIDUAL ❑ OTHER <br /> FACILITY FILE <br /> FACILrrr ID# `� S CROSS REF ID# ACCOUNT ID# I O �� INV# <br /> PL THE FO WIFArjl TTY I SITE UPORMA77M <br /> No <br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES <br /> YES No�J <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? <br /> Bus,NEss/FAaLrrY/STrE NAME rJ P r l7�� s a 0`) 8 3 <br /> �, SUITE# BUSINESS PHONE <br /> SITE ADDRESS a \„ '2 U� � S � �<\ <br /> STATE zip <br /> CITY g-0� <br /> EDOFSuPERviSORDSTRICT <br /> LOCATION CODE KEY1 KEY2 <br /> Mailing Address ffDIFFERENTfrom FacilityAddress Attention:or Care Of(optional) <br /> STATE ZIP <br /> Mailing Address City <br /> r <br /> CODET,L APN# a s ^ s O i COMMENT: <br /> THIRD PARTY BILLING INFO: Completed Billing Party is different from Property Owner or Facility Operator identified above. <br /> Attention:orCare Of (optional) <br /> BUSINESS NAME <br /> PHONE <br /> Mailing Address <br /> STATE ZIP <br /> CITY <br /> Arrn MT 42QRf"for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BnrnC A."C'OMPI IANCF A(KNOwI.Rrl(MF.NT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I aclmowledge that all PERMIT FEES, <br /> PEAAL77ES,ENFORCEMENT CHARGES and/or KOURLYCHARGES associated with this operation will be billed to me at the address identified above as the Ac OUATAnn ESS for this site. I also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN CO 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 ddress, he by autllorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEA TH D8 ENT as soon as't is av a and at the same time it is <br /> provided to me or my representative. —•'� <br /> PLEASE PRINT SIGNATU , <br /> APPLICANT NAME re✓I� h�` <br /> DRIVER'S LICENSE# <br /> TITLE (7. ^ G1r,.� (PHOTOCOPY REQUIRED) A19/14 -� <br /> Approved By <br /> &11"_-_ Date D- Accounting Office Processing Completed By /' Date <br /> 29-02-002 April 25,2003 CONFIDENTIAL <br />