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MLD <br /> ' �n <br /> San Joaquin County Environmental Health DepartmerptcF' ?14 <br /> DATE <br /> 4u� �1`4,�t,-UNIT <br /> RE <br /> GEN FORM <br /> y <br /> MASTER FILE RECORD INFORMATION 1114-FR"R" <br /> MAY 2 5 2004 <br /> ON IV f <br /> OWNER FILE <br /> COMPLE7FTHEFOLLOMNGPROPERTY OWNER INFORMATION; CHEGTYIF OWNER CURRENTIrONFILEWnN EHD <br /> PROPERTY OWNER NAME fy <br /> PHONE �./„ —Z <br /> Z y <br /> First MI ((' L J(J <br /> Last <br /> B1157Pff55 NAME 1,t / SOC SEC/TAX ID# <br /> Owner Home Address <br /> DRIVER'S LICENSE# <br /> City <br /> ,t STATE ZIP <br /> Owner Malting Address <br /> /I Jag?# <br /> Mailing Address City <br /> StTp-V1/ Stat <br /> TYPE lMQWNFD6mD <br /> �1•, <br /> CORPORATION❑ INDMDUAL❑ PARTNERSHIP <br /> FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACIUTYID# ry CROSS<REFID#: ACCOUIYTSQ# INV# <br /> POF THE LL n N' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES IF' No ❑ <br /> Is this an EXISTING Business LOCATION but aalN}Ew/TYPE of regulated Business? YES/❑ No ❑ <br /> BUSINESS/FACarTY/SITE NAME / f�!//t/ l✓l � V'V/ ` [t� � f/GG`���'L <br /> SITE"MESS / 7 ll--AW T&/ <br /> �,�j �jI SUIfE# BUSINESS PHONE <br /> CITY STA154 ZIP <br /> Mailing Address&)ffD1FER � � � 7� Attention:or Care Of(op[r <br /> Mailing Address City y C , STATE/1- ZIP <br /> THIRD PARTY BILLING INFO; Completeif Billing Party is diferentfmm Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:OrCare Of (opliona/) <br /> Mailing Address PHONE <br /> CITY <br /> STATE ZIP <br /> e.QQ LM9KAD0AEsN for fees and charges <br /> WNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMET TANr'r Ar' W1 FDGME : I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERAHTFEES, <br /> PENAL77ES,ENFORCEM.CHARGES and/or HOURLYCHARGFS associated with this operation will be billed to me at the address identified above as the Ar'I' ZTADD=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 SANJOAQUINCOUNTY 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,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHDEP <br /> provided to me or my represen rve. 7 as non it is ail8ble and at the Game time i1 is <br /> APPLICANT NAME LEASE P <br /> SIGNA E � <br /> TITLE ���A t�✓ <br /> 'v DRIVER'S LICENSE# <br /> fPHOTOCOpy <br /> Approved By Data REQUIRED) <br /> Accounting orrwe processing Completed <br /> 29-02-002 April 25,2003 By <br /> Date <br />