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San Joaquin County Environmental Health Department <br /> DATE 0'4 JOS MASTER FILE RECORD INFORMATION"MFR`P GREENFORM APR 10 <br /> ZOIZ <br /> SHAPESCII)EOR jID —' SITE I�� Tu <br /> OWNER ID/ /] =57- <br /> 11ryu��rL�'{•,�,,,n(]•In'IEAL HCASE/ 5kd V a 1f71Vt�'�slPl/P��YIyFCrrl/{V[)IiES' <br /> OWNER FILE-CONPLETE ry/EFOLLOW/NO PROPERTYOWNER/NfORMA7JON.' CKEl OWNER cugONSIll ,vnLeernr EHO <br /> PAOPBMGMW AkmE p <br /> �"Jh <br /> r�E DaN 32-�'T1 <br /> Hrsf M/ <br /> Ej <br /> BUSINESS NAME 1 I e LB9( �1�s <br /> r_svN Y Atv U CA l'\t LC— FgNENUMBER I Z I !-7 <br /> OWnarNane Acidness �1_ C. EiWLADpgE88 <br /> f'Y1ecnAry� Inca:'JY 4.aw�c _Oh <br /> CMy <br /> Nr <br /> OMWMaEklg Add, STATE yp <br /> 60x IbQa <br /> MaIIAIg Addreu city <br /> ictiKs,9al CA � <br /> stet, „P <br /> C0APORut TR01❑ - <br /> INDMDVAL❑ PARTNERSHIP❑ <br /> 817M MnIOATION_ I FEDADENw❑ <br /> ENVIRONMENTAL ABiC{>1Mp,R_VOWMARY CLEANUP OPHER <br /> FAwuTr IDY '-'WAS QUALITY_HW PVELINE INVESTPOATION <br /> INVM Accouxr l0 pq-y RDP _LOP_ <br /> A9SIONEO EMPLOYEE LEADADENCY:EHD�gyyppq_0T8C_EPA <br /> IS Sa I(PILE COMg;Ayf //E FOL LOW/NQ BUSINESS/FACILITY/SITE/NFORNA Ill <br /> Is this a NEW Buelnesa LOCATON not previously regulRted by the ENvfgONMEN7AL HEALTH DEPARTMENT? <br /> IS this an EXISTING Business LOCATION bUt R NEW TYPE Of r uleted YES El 140BUSINEESIFAw e8 BuslnBea9 <br /> LntY/Sf1ENAME YES ❑ WD <br /> 81TEAroREss <br /> 9 1 43 j I Q yJ/[� aD EN <br /> CITY r� `�� OVJ a� Nol All BUSINE88 PIpNE <br /> LTCA�•nl - '� �� <br /> LP <br /> BOARD OF S UPERVISOR DISTRICT <br /> Oy LOCATION CODE v/V Kfl.T <br /> Melling Addreas KO/FfERENr/rtrnfeo KEY2 <br /> //lfyAddYsea <br /> '0 I QV Attention:orcere Ol/9oEov+e// <br /> Melling Achy ^1 �. �00 <br /> CA1 SO 1 9 STATE zip <br /> BIC CODE APHE u <br /> COMMENT: <br /> THIRD PARTY BILLING INFO- Comp/sten ir ounnoll Party is different IromPrO Owner arFacllity Operator identifiedaGove. <br /> BVSINESSNAME I <br /> O Attention:arCero Of(V#AAn // <br /> MasslgAdd-. <br /> PHONE <br /> CITY <br /> STATE ]UP <br /> ZASIPAW Aor Aea endohergee OWNER <br /> FACILITY/BUSINESS THIRD PARTY BILLING <br /> DILLIND AND 0011 LIANC'F A A 14 <br /> 1,the uuderslgnN A ival,a Ih#I am the Owner, <br /> YENO.nEt',trvfnAYe,16vrC7um;c5'ond/or/IrxiRl.r C/uRrLT ncsarialed wllhl [s oiNmson»111 be billed to me al the adtlrrss ldentlfiN above us theAaTNmvAmm <br /> O/Nro7 orduT H::Agent of Ihb Business,and 1 aclmowlNge Ihat all PERNYr F"EF:T, <br /> all information provided on the applicationLaws <br /> a Ione and Thetions,;and that all regulated acdvldea will be performed in accoNance with all cc AT thle SANdDADDLY C'OD.Yr t Ordinance I R Cedes Char <br /> Standards and SPATE amUar FEDEMI.Iews SndN p 1 y mfor thissite. leen reran that <br /> encl <br /> any end oil results and'mumamenlal assessment InfolrmeHon tatS,TNedersigned owner,operator,oral All JOAQU[N COUNTY ENVIRONMENTAL NEACTIIenF;l AN'ITIFSN'I'wNsoonsim It k Brei Ic and at the same time it is <br /> A' Address, le andatfile.the renews of <br /> pmridN to me m'my repmrnlenh'e /.f�dssN L.mN� i <br /> APPLICANT NAME P p F C�++� Ll,� / <br /> I LEASE PRINT) \I r�N SIV ^y _ 1_/j f <br /> n(.� yYI'FAYt1 '(� 810MATIRE <br /> TITLE �/ ) <br /> b�"LL TAx ID 1f <br /> t4ITTION <br /> Dale _ -- — <br /> A00ounU Omoo Pr000a77i <br /> AMOUNTPAID DATEOFFAYMENr emu <br /> P3� ,� y-ra-rz !� RECEIVED BY58 erg Z 9so <br />