Laserfiche WebLink
Feb 09 05 1 : 8a WDC' Inc. "/� � ��l (57(0/01/18/2gj5 12:5 1. A zua V40vo �S <br /> � 0,i 6� 9022 p, 2 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT M 1 <br /> MASTERFILE RECORD INFORMATION FORM � E O V O <br /> r <br /> ?L&U i <br /> SHanmSEK T10NSMREIfDUSEONLY OwNERIDIR J�_� �(�I��S CASE 1t C� <br /> v —OWNER FILE <br /> COMP TE THE FaLLOW(NGBUSINESS OWNER/NFORMATION: CHECX)F OWNER CURAEN -14;6, <br /> ky/7If 117' <br /> BUSINESS �(Z c lm* + ( PHONE D°4 <br /> OWNER NAME LFirerI Leer g3�-- 7p� <br /> BUSINESS NAME(H ditant howl ower Name) /� <br /> L/1ViVt �JJ"Tk rCs <br /> OWNER HOME ADDRESS "71f o/ ec,rCs Asa <br /> C(TY /`QC 1 STATI[i Z1P <br /> 9S3o� <br /> OWNER MAILING ADDRESS(IfdMbfwthwnOwnarAddress) AttandonorCam of <br /> 75-0 <br /> 4 S !/a./ /"o u <br /> MAluNGADORESSciTr G STA ZIP <br /> QS3a f <br /> TYPE OF OWNERSHIP; <br /> CCNIPORATON 9 INDIVIDUAL❑ PART4ERSMP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY[: FEDAGENCY❑ t7 WR 0 <br /> FACIUTY FILE <br /> FACIUTY ID d: (- U/5-'731 CO-OWNER ID li: AIIGUNT ID#—. 6.2 773 <br /> OMPLETETHEFOLLOWJNG 8 ESS FACILI ATIDN <br /> Is this a NEW Buclnass LOCAToN or VEHIcLF not pmvla usly ragulabed by the PJAMONMBdrAL HEALTH DEPARTMeM yra Q No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of fogulatod Suslnese7 YES ❑ No <br /> Bu$INE93/FAGUTYNAME(TtnaMA6clhoBuswrssN nrhe ALTTIPEFUIYT) ES-bde <br /> FACILITY ADDRESS(If FAcrurriz a Moeat F000 UMror F000 Vo-vag use the ['•_ <br /> `'7-7O �_Wr &41-S Ad <br /> / BU61NE33PHONE <br /> `` <br /> CITY(IiFACa/n lea NO&"FovoLtrurorFaoavr�r2�ossUw(!^g^ed+r� O( STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE EYT KEY2 <br /> MAILING ADOnss,for Health Fe+rnit(I(otr-FeRF-urr�.n Faday Acarese) n Atborrtfon wCara Of <br /> /s-17 5- l _ A Oe t��oyl S7eQol' <br /> MAtLMG ADDRESS CITY +rA C A <br /> STATE A ZIP <br /> SIC Cove: AAN* Nq^Q q( -061? C..hE m C <br /> ACCrt1/MTdAAQFt7Q forfeasandcharges: OWNER FACILITY/BUSINESS ❑ <br /> RTI.I.Mr AND CQAZr IAnrrc !tctnvr»vt rnt'MrNr• 1, the undersigned Applicant, certify that I am the Owner, Operator, or Awhuri;cd Agent of this <br /> Business,and I ack owledge that all PEAHrr Fear,PENALTIES,ENrrmcnwENr Cf ARGEs and/or H0UffLYCJG4IrGET m3sociated W"this operation will be <br /> billed tome at the address identified above us tbeA-rn»vrAnn Fsr for tbh site_ 1 alsu ecrtify that all infornurtion provided on this application iv true <br /> and correct, and that All regulated activities will be performed in accordance with all applicable SAN JoAQurN COVN-ry Ordinance Codec and/or <br /> Standards ano RTATF. d MMAL T. ws and Reirmlatinns, <br /> , r { <br /> APPLIGNTNAME- e 01114 r/It�/N�J� 81GNATlAtE: I <br /> Cf <br /> w' PAMLM Ortnt <br /> �r- /Y <br /> TITLE: PA r / 1-• LLC DATE DRIVER'S LICENSE 0 <br /> Approved By Gats Accounting Office Processing Comple6od By oats <br /> A PiROGRAM(EMD 48-02-034 Pink)or WATER SYSTEM(END 4602.003)form tautd t)o completed for;; b EHD.gated oporation at this LOCATInN oxcept <br /> UST Program(Uso SWRCB formal <br /> SHO 48412-035 p <br /> 10/9/21703 Mast0HRappq L <br /> RECEIVED <br /> �L? <br /> FEB 1 0 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> 02/09/2005 WED 11:45 [TX/RX NO 92811 Q 002 <br />