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San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> adNomAE11DJNaDwLx or;rmN:lAlp C,,.. UNIT IV <br /> OWNER PILE <br /> COMPLETE ThIFFOLLOWNIGIDROPERTY OWNER lwawwnav: C: Ke OWNER CUKKEKnrGvnuwrrN END <br /> ^�^TDbom K e eY r1XIfa <br /> Fief M/ "St <br /> E""'""" �. I Ual ► c) !e$ ISOOSWITAAIDS <br /> OvermrNmne Addrew DAfmre L,awea <br /> CRY STA- L <br /> 0a6ox 7576 <br /> MWWWAd& -C"y S To 04c fioY, "A"'CA zo 75A 6 7 <br /> t• ATeRr❑ INmM1lpml❑ PANtItiWM❑ r®Aeeac❑ nrrla� - <br /> PAOILITY RLE <br /> aMel„Tae �o�� CIIWRsRYN AgOatpNrNYf <br /> CDwwUFTEIMF LLO*mBUSINESSIFACILITY/SITE/NFoAwAnoN: <br /> In dlb ANEW Buepwee LOCATION not prevlmNly regulated by DNI EWI0ONMVaAL HEALTH DEFT.? Yb ❑ Na X <br /> Is Dde m EXISTING Bu.Mlp.LOCATION buts NEW TYPE afregu4tad BueBlepr Yn ❑►' /f NG <br /> BUW*UrAClnWBa[NAFOYrAW A S v�Le. S�at�cA W <br /> V ca.nt <br /> SMAS [3� 0r l `'W • Ge ^amIA "It DIyI n. wi�a Ml"ma.pN <br /> GI" J^IOCK-r&A STATaa L ISR 5 <br /> 1dpAllbM/1bGe Irain KM <br /> IYIIYp Addrw NDNgMW Vraan F&aWAd, AVAnaen:a Can Oftgatlprlmp <br /> Melee 1 11 Clly 8TATE L <br /> NgDO"M AF Ie ¢ ;: <br /> TIRND Pfutrr OILLINa IN/tx Complete KBilling Party is dpferant from Property Owlwr O FscRfty Operator identified above. <br /> Roww-& * ASSbaaX-S or SX l`TU <br /> '"tee" t 'iK9 R%Vt4r&i ctL Ori tie Sane 0730 " ° 7,07-136--41S,570 <br /> a," Son D,A A or 1759 76 <br /> d for Aee and chargee OWNER FACa.DYISUMESS THIRD PARTY BILLING <br /> Bat G we o r•wn ACXNO ' : L the underelpd Appacam.car"IW,l Am dw owAv,0ymrw,w Awb1Md AAed of tli Nations,W I ukwwkdte dimal IlAAGfFTLi, <br /> M'M.P6,EwitMc'EA¢ATCLfAfl3W/w HGUALFCIfMGdl AwdAM wiH tlu Apendm W DI b<bDled m mr e,dw eddrs idmdAd Ab w r,hA Td�N�f(ar drir sae I Abs card!,dr, <br /> aisles den pro,idel Ae dds ApprsadoA u eye W m... W dm,.0 rePJAW AetMBn will be performed b rmrdmm with d Applicable SAIF JGAQM CaMrT Odma Coda m&w <br /> Smtladr W STATr eaNw FLDrR1l lae Amd RgWAtmm.N the onde,dLed Awem,apmamr,w ateA,Aftlr pnpen2lomtld e,I6e Above feelS,y/dw Addrg I Ire,Nr AeWOrir We rt4re d <br /> Aq Ad N rerlb W mvVeAAffaW..I Naformasom m SAN JOAQUIN COUNTY r.NVIRONAIENTAL HEALTH DPRAATAVJ u woe r 1,Y Aa&bwW W at ae Nme date Y It <br /> p,oWd m me w W reprmmt. *t <br /> AIILICANFNAME oe ,v Ce! / p pm SIGNATURE I• <br /> TrrLE 5r, CG? ►1' QytA DRIVEWBLICENSEaI <br /> Nmmmdb Dem GRIw D+ 6 <br /> 79-02 IWI2AI-, MASTER FILE RECOGREEN <br />