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San laquin County Environmental Health •artment RL En <br /> DATE Z5I UJ MASTER FILE RECORD INFORMATION "MFR" I \ <br /> Roan <br /> cwnns.rows f9pfI� ENA <br /> ( o AI �fj(IC <br /> OWNER FILE PERMIT/SE <br /> COMPLE7E 77/EFOLLOwNGPROPERTY OWNER INFORMA?TON: fif£arF OWNER NaaeTmraR£n£ <br /> PROPF OWNER NAME ao .f PHDN 10 2-OZ.7 <br /> First Ml Last <br /> BUSINESS NAME n r SOC SK/TAX I D# <br /> Owner Home Address 5-��. l,y�`t A DNNEWS LICENSE# <br /> City 5"F"tiG�l:.- 1 � �`�� z STALE <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> Tvoo r,o nrmroo..o <br /> CORPORATION INDMmMALL PARTNER El FID AGENCY❑ OMER❑ <br /> FACILITY FILE <br /> FACDJTY ID At CROSS REFID# ACCOUNT ID# �— _W# <br /> P LL j� 77NaO <br /> Is this a NEW Business LOCATION not previously regulated try the ENWRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an E70STING Business LOCATION b^ut a N1Ew TYPE Of regulated Business? YES ❑ No ❑ 1 <br /> BlTswas/FACDIiy/ELLE NAME 's <br /> SITE ADDRFS 1 0 4 1 H V SUITE# BUSINESS PHONE 'V <br /> 1 t r N <br /> cm '1,I, \ n c0. STATE(I� 7]P <br /> Vv\ 1\ C N <br /> Mailing Address ifDIFFERENTfrorn FadlityAddreer Attention:or Care Of(opHanaQ <br /> Mailing Address City STATE ZtP <br /> THIRD PARTY BILLING INFO- Completed Billing Party isdifferent from Property Owner or Facility Operator identified above. <br /> BIISINEss NAME Attention:or Care Of (optional) <br /> UCttn 1�(©-in <br /> Mailing Address93 PNONEf) - 7 /or7O/ <br /> Cure Kit �/l.1 Cl'V STATE A /ZIP CJrT /�L /KJ <br /> 41=9u"'olulau`for fees and charges OWNER FAOIuTy/BUSINESS (, THIRD PARTY(/BILLING <br /> Rn.rmr ANn Cniwruaure.ArXNnws Fnrmrn^r. ],Ne undersigned Applicant,arliy that I am me fhvner,Opermor,or AuTAodudAgenT of this Budnas,and I acknowledge that all PERaRTF£ES, <br /> P£N.(LD£s,ENFORCPAT£MCHdRGPS and/or HOO£LYCHA£CFS associated with this operation will be billed to meat the address identified above as the A(X01WAODRFyy for mis rite I also mrtiy mat <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 JOAQNN COONS'Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. Astheundersignedowneroperatoe oregent oflhe property located a heagove facility/site address,l hereby aumorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP NT as soot I ' d at the same time it is <br /> provided to me or my repr iv.APPLICANT NAME � PtFASE PItafr SIGNATURE <br /> TITLE r rs/ V L DRIVER'S LICENSE REQUIRED) <br /> APProvad BY L� Data Accounting Office,Rocecsiug completed iv Date <br /> 29-02-002 ApnI 25,2003 <br />