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'1a <br /> San Joaquin County Environmental Health j <br /> f <br /> DATE MASTER FILE RECORD INFORMATION - FORM <br /> cL•,,•••..s...r,.sunvisa r DwflR IDill r <br /> CASE x <br /> !�h , E UNIT IV <br /> PLE7lr MEFOLLOH7IVGOw"M ifs �i <br /> �J <br /> PROPUM Ownet Nut 'ERTY OW rNFARMATI�VY' `5lE t ON F"WnN EH D <br /> � a N4 Pry (Z-o`1) 1,44 - gyzZ <br /> Firo MI Lest <br /> etisvaess Nut g 0 A-,So c <br /> SOC Sac/TAx ID>Y fJ A <br /> owns Roma Addren 134 W {Zo g I tJ A-a o D iJ R• S — DRJIM'S Lxem* tj A <br /> cfty S i'oc k�o �1 C A Ll q 10-7 STATEm <br /> C A 9 S Zo-7 <br /> owner MaWnp Addrom <br /> Malikp Addrps qty <br /> State zip <br /> COM"ATION❑ DCV#U W❑ PAN►►ER9t8❑ <br /> F®AW1CY❑ Ong:��,d <br /> PA LM PIS! *�m <br /> FAC=T ID Ile CfeOss RB ID ACCOUW ID it 1W* <br /> 7ADOREM <br /> 7.*=TI <br /> ot Pfeviously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No lid <br /> IONbut a NEw TYPE of regulated Business? NESS <br /> /� YES ❑ No ( N.4WE <br /> BUSIN1ESS/FACnrrY/SrI`X NAME <br /> - - -- <br /> 33 o "i Sums BUQ►�s PHONE <br /> Cm 7_0►J <br /> sYATe zm S Z I <br /> DOMW cf SWERVaM DZPF= LAa►MM CODE Tari <br /> 77 <br /> M"kq Address#DDq�/PE/ ft"A*x0NyAd1&,&v AmeTwort:a Caro Of(getiwsN) <br /> M&WV Address City <br /> STATE jm <br /> SIC Co.. AP" <br /> COMNEftr. <br /> TNam'AItTY SIWNO INPot CaWkte if Billing Party a dfff&&7t fmm Property Owner or Facility Operator identfWabove <br /> Bum'asS NAME ! SRT cO N S u c.T l►J INC . <br /> 7 1 AtceTwon:or Care or (cnelo+„n) L TE V <br /> Malang Address F. n, 30y. 4+ 40 , PWONE `11�) <br /> CITY <br /> +<L V0 iz 1VD0 �4+ CA, W3-7f--L STATE lA zw 9 s 76 Z <br /> ImWAlzApom for fees and charges OWNER <br /> FACILITY/BUSINESS THIRD PARTY BILLING <br /> HcaJJNG AND(romp'JANCZ ACKN:ti.^FDMsn—. 1,the undersigned Applicant,certify that 1 am the Owwer, <br /> ftVALTTM,ENFORCEMEMCmAjtcEs and/or HOURLYCHAR(.W tea.or Awdaiu/Agae!of this Business,and 1 acknowledge that all PEAAl1TFELT, <br /> all information provided on this application is true and correct;and thatallregulated activits Operation ill be es will lled tome at the be performed inaddress accordance twiith al��aicabk SAN JOA <br /> d�'da06EYf for this site. 1 also certify that <br /> Standards and STATE and/or FEDERAL Laws and Regulations. N We undersigned owner,o PPI QUIN COUNTY Ordinance Codes and/or <br /> tg operator,or agent of the property located at the above facility/site address,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME S�(= PRIXT <br /> \J C PLEASE <br /> �p--T SIGNATURE <br /> TITLE PSS+or�T Se 9-T Co NSU:-T) jj6 INC <br /> DRIVERS LICENSEC-L5 0 7 1 S G <br /> Apporad sy otw. Atzoutrhq Onke P,00.dne coo phM By <br /> 29-02.002 Apn1 2S,2003 <br />