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San Joaquin County Environmental Health Departmeni�)(����( p , <br /> DATE - >'��S MASTER FILE RECORD INFORMATION "MFR" I <br /> gHAAnFn AREAS FDR Flan USE ONI OWNER ID# �) (G-4a CASE'# _ �U MTOW <br /> OWNER FILE L'yECKIF OWNER /�NtC�2� HD ElCOMPLETETHEFOLLOWINGPROPERTY OWNER INFORMATION; <br /> PROPERTY OWNER NAME PHONE <br /> First MI Last <br /> Sot SEC/Tax ID# <br /> BUSINESS NAME <br /> DRIVER'S LICENSE# <br /> Owner Home Address <br /> STATE zIP <br /> City <br /> Owner Mailing Address / :5 ,33 <br /> / <� <br /> Mailing Address City 4-V t. t-4-u-, l State� - Zip <br /> n'PF DF ITWNFRGHTP <br /> CORPORATION ElINDMDUAL <br /> -1PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> 1 ✓/y/y ACCOUNT ID# INV# <br /> FACILITY ID# <br /> ]TCROss REF ID# <br /> MPLETE THE F LL WIN NF RMATI N' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No Si <br /> BUSINESS/FACILITY/SITE NAME L�� •�� ) - 1 <br /> SITE ADDRESS SUITE# BUSIN PHONE / <br /> f /L L^gif/J r 7kx° &L IT G�/'�aY '� h <br /> CITY <br /> STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KE11 <br /> KEY2 <br /> Mailing Address ifDIFFERENTfrorn Fac//ityAlddress Attention:or Care Of(optional) <br /> SYAI ZIP <br /> Mailing Address City <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: completeif Billing Party is different from Property Owner or Facility Operator identified abOve. <br /> Attention:or Care Of (optional) <br /> BUSINESS NAME <br /> PHONE <br /> FMZ�iflring Address <br /> STATE zip <br /> CITY <br /> Arv'ouNx apR"F for fees and charges OWN,94 FACILITY/BUSINESS THIRD PARTY BILLING <br /> Rn TING AND COMPL IANCP ACKNOWLEDGMENT: 1,the undersi ed A ant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PEIcnnTFEEs, <br /> PENALTIES,ENFORCEMENT C11ARGES and/or HOURLY CMARGEs associated with this operation will be billed to me at the address identified above as the ACcaLzTADDRR_CC for this site. I 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 and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,l 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. PLEASE PRINT �� / <br /> APPLICANT NAME SIGNATURE nS� <br /> DRIVER'S LICENSE# i/ p <br /> TITLE / ----' (PHOTOCOPY REQUIRED) r� L / 7 <br /> Approved By <br /> Date Accounting Office Processing Completed By Date D <br /> 29-02-002 April 25,2003 <br />