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San •quin County Environmental Health•partment <br /> DATE � 25V S MASTER FILE RECORD INFORMATION V`MFR" <br /> roawn...c Acer AUG- ---� N <br /> ENV A —1.1 t, .LTIT_ <br /> OWNER FILE pERM7/SE k1� <br /> COMPLETE THE FoLLOwrNGPROPERTY OWNER INFORMAUON; CHEOIrF OWNER NasExrzronFaE El <br /> PRDPERTYOWNERNAME IA A •YniPN V.O 2—0Z 7 <br /> /L First MI Last <br /> BUSINESS NAME n C( SMSM/TMID# <br /> Owner Home Address _I WC5 t' 1 DRrvER's LlCUuE# <br /> City STATE <br /> ZIP <br /> /� J <br /> Owner Mailing Address <br /> Mailing Address City state Zip <br /> ivnc nc nam <br /> CORDO rinsi❑ INOMDUAAx PMTNER El FEDAGENCY❑ OrIER❑ <br /> FACILITY FILE <br /> FACILII TD# CROSS REF ID# AmouNr IP# INV# <br /> COMPLETETHEF LL0KWG BUSINESS / FACILITY SITE INFoRmAww <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT. YES ❑ NO ❑ <br /> Is this an FmMNG Business LOCATION but a NEw TYPE of regulated Business? Ya ❑ No ❑ <br /> BUSmESS/FAmITY/SITE NAME Vr A. t � 11.... <br /> Sire ADDRESS �� I �VD Ko �W 11 `( sum# Bu&RSSPNDNE <br /> '��It\ 1r� �.(y v V r <br /> CITY Mick\� \\k eco, STATE IIP S <br /> Mailing Address/fDrFFERENTfzosn Fadfitl•Address Attention:or Care Of(optional) <br /> Mailing Address City STATE Tm <br /> THIRD PARTY BILLING INFO; Completed Billing Party isdifferent Irom Property Owner oFFacility Operator identified above. <br /> BtR[eg55 NAME p Attention:or Care Of (opHssnaQ <br /> USN i OYi <br /> Mailing Address <br /> CDy 11t��� 1 PHONE .O- � & S4o2O//O <br /> SAT0oE <br /> for fees and Charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> I,the un lenigned Applicant,certify that I am the Oaoee,Operator,ar A.atvrfzed Agent of this Bminecs,and I acknowledge that all PmurrFEPB, <br /> PENJLmS,EwOschsmalCt zs and/or HOURLYCAd a associated with this operation will be billed tome at the address identified above as the AM01VVrAODRFfa for this site. 1 also certify that <br /> all information provided on this application is Vetoed correct{and that all regulated activitim will be performed in accordance with all applicable SAN JDAQM COumY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,oragent ofthe property located a;. ove facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE +NT as iso is•e.,on•r.5 d at the aame time it is <br /> provided to me or my repro <br /> APPLICANT NAME PtEASE PRIIfI SIGNATURE <br /> TITLE //J DRIVERS LICENSE# <br /> K/ V uQtmtEO1 <br /> Appeased By Date Accounting OtFm processing Competed By now <br /> 29-02-002 April 25,2003 <br />