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DATE San Juin County Environmental Health"oartment <br /> MASTER FILE RECORD INFORMATION "MFRS GREEN FORM <br /> SHADED AREAS FOR END USE ONLY OWNER ID# 1715 tl_os CASE# �n Uo/ 3j5 UNIT IV <br /> I TrOWNER FILE <br /> COMPLETE THEFOLLOWNG PROPERTY OWN ER tNFOIJ T/OM"y / CHECK IF OWNER CURRENTS r ON FILE WITH END <br /> PROPERTY OWNER NAME L o 11 —r-rE GNL1;�-L.14 -b-r PHONE <br /> Fist MI Last <br /> BUSINESS NAME <br /> A � [���(] /f/ Tax ID# <br /> Owner Home Address 1483 �{'Ct�WI`� u( DRIVER'S LICENSE# <br /> oily LkTFElzo{J <br /> STATE CA, <br /> tiA 7JP gs33 ID <br /> Owner Mailing Address L� <br /> Mailing Address City state Zip <br /> TYPE OF nwismooluop <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ <br /> OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# n l o,-S� 089 REF ID# 111,` ACCOUNT ID# INV# <br /> of S3tb89 l J 3� <br /> ` 93b <br /> COMPLETE nTE FOLLOWNG BUSINESS If FACILITY If SITE fNFORMAT/ON,' <br /> Is this a_NE_W B_USIness LOCATION not previously regulated by the ENVIRONMENTAL HEALTH YES ❑ No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No ❑ <br /> BUSINESSIFACILBYISITE NAME 570C910gJ CHARTGf( (JAY COAAM11 I) r(UME CIO STANT[•C CONJuLLTrJG CORP. <br /> SITE ADDRESS 52 (JEST SUITE BUSINESS PHONE <br /> 8 CHARiCft CJAY qlc) Gl-odCb <br /> Cm STOC14TON <br /> STATE CA LP 9521 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Addreas MDIFFERENT from Facility Addreas Attention:or Care Of(opNonW) <br /> 3017 1<SLJ RI , SI /OO .f,3/zTAN I' l", UFF <br /> Mailing Address City fl A"(AO COrzDovA <br /> STATE (,ALP 9S�J0 <br /> SIC CODE 11 APN# /650gJ COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Of Attention:or Care ( L'onalJ <br /> STANTEC CoN,i�LTSNG Coop Attention: <br /> ,.h GJF,rrHDFt= <br /> FMallingAdd-- 30)-7 I<rl,J Rdgb, SI /00 PHONE (q Ic)8G1_0y00 <br /> CITY RANCIIG CDrI $TATE CA ZIP 9r67o <br /> AaaaaaaA <br /> ACCOUNTAOOREa9 for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE AClcrvowLEpcntervr: 1,the undersigned Applicant,certify that 1 am the Owner, AaaaaaaaaA <br /> Operator,or Aur/mI Agent of this Business,and 1 acknowledge that all PERMIT FEET. <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURL ICHARGE'S associated with this operation will be billed in me at the address identified above As the ACCOUNTADpRESS for this site. I also certify that all <br /> information provided on this application is true and correcC and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN CotmrY 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 informafion 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 rr�� PLEASE PRINT <br /> /J2TAN CJEJ rNrOFF SIGNATURE <br /> TITLE <br /> SF,vIO2 GFo<oGTsr <br /> Approved By Date AeeouMing Office Processing Completed By ZE1- Data �0 l <br /> 29-002 April 25.2003 <br />