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San Jelin County Environmental Health D*rtme�t__ <br /> �r l _,Il GRN FQl{l+�' <br /> DATE 12, V b MASTER FILE RECORD INFORMATION "MFRff <br /> EnARFA%Eno FHnljcenmlv OwNERID# NOV UaI •}��''J� <br /> IV <br /> !Js lllOWNER FILE CN�Vrlfi�ufy�ll l nj I��I BILI i-) <br /> CHECKIF OW14wtr il�Nt3kq,V;itE?�u' N EHD ❑ <br /> COMPLETE TNEFOLLOWI aPROPERTY OWNER INFORMATION: <br /> PROPERTYOWNER NAME PHONE 9/6 -333 <br /> First /MI Last <br /> BUSINESS NAMra, I'�I )�� MµKSI +s SOC SEC/TAn IO# <br /> C' 11 """��CIU `V DRIVER'S LICENSE# <br /> Owner Home Address <br /> city l� l `\ /� STATE ZIP <br /> Owner Mailing Address ^7"�U 1\v �,45 f UCJ S C) 1 <br /> Mailing Address City Q J/ CCJJ Zt— Jr rp SSS/ L <br /> TIF ri. v ` J Ol7 <br /> n'BE <br /> CORPOMTSONX INDIVIDUAL El PARTNERSHN❑ S FEDAGENCY❑ OTHER El <br /> FACILITY FILE <br /> FACILITY ID# pn/ CRO55 REF ID# ACCOUNT ID# e; /Q INV# <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an DUSTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FACILITY/SDENAME s( � �� !L(iG(, <br /> SITE ADDRESS 1 ��'F�✓✓�rr//�����r ' ^ SUITE# BUSINESS PHONE <br /> CITY (/N/•L^^,/ STATE IIP <br /> BOARDOFSUPERVL'AIt Dummacr LOCATION CODE KEYS M2 <br /> Mailing Address/fOIFFERENTfNOrn Fad/1tyAnomnr Attention:or Care Of(optional) <br /> Mailing Address City STATE Tap <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is dilferentfrom Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of (optlonal) <br /> Mailing Address /�,� 0 PHoxE/(tAtG\ <br /> C— CU1P—V j-pQC V yyy ✓// CCC �A L7T) SOP !SV(T $ <br /> Rrr'nuliT Annn"ir for fees and Charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> B C eNCr Argnnw Encmavr; 1,the undersigned Applicant,certify that I am the Owner,operator,or Authorized Agem Df this Business,and I ac age that all PERMIT Fe Es, <br /> P£NALTvis,ENFORCEMENT CHARGES and/or HOURLYCHARCFS associated with this operation will be billed to me at the address identified above as the Arrn,,NTAODReCC for this site. 1 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 COUNTY Ordinance Codes nd/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent ofthe property located at the above facility/siEff <br /> [he release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR as oname fime It Is <br /> provided to me or my representative. v��) E PRINT <br /> APPLICANT NAME �GIa•L,4s lL .� SIGNATURE <br /> TITLE S4 p, ' DRIVER'S NSE# \ "/_'1 <br /> �i-�V 1 / GCf• DRrVECOPYREENSED, )/�6� 1 <br /> App ad By Data Acmundng Olfi¢processing Completed By Date ��� <br /> 29-02-002 April 25,2003 <br />