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0 0 <br /> San Joaquin County Environmental Health Dep P ` �`) <br /> Ftp N F l)1 rt <br /> OATS MASTER FILE RECORD INFORMAnoN I�MFR 1/ <br /> i <br /> r;p.nrn.praww Pun neonate i UNIT IV <br /> OWNER FILE <br /> Q0MP M7NEF0LL014TNGPR PERK OWNER INFORMATION; OsSQVff OWNER CURR£NTEYONFA£wlrN END <br /> PROPERTY OMER NAME Jl9 y c/�_ <br /> CJ r First MI V Lest a Q <br /> BUSYNESS NAME SOcsK/TAx ID# 3 V9 <br /> Owner Home Address� DRIVER'B LrcEr15E# <br /> e, <br /> city <br /> 10 lJ STATE ZID (/ <br /> Owner Mailing Adgreas <br /> Mailing AddressZip <br /> City Sts <br /> Y <br /> Tvpc KtlWNCpCMp <br /> Co Isonarmf❑ INDIVIdIAL Pm NERSlIP❑ Fee AGENCr❑ OBER❑ <br /> FACILITY FILE <br /> FAmITY ID# CROSS REF ID# ACCOUNT ID# INV# <br /> CompiLEirrTHErmLooTNG BUSINESS I FACILITY I SITE MwRxATxoN. — <br /> Is this a New Business LocATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMEMI. YES ❑ No <br /> Is this an EmSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ N <br /> Bumtrs/FAtam/SNENAME --)— <br /> sonA Beers / r S SUITE# BUSINESS PHO <br /> N <br /> E <br /> c" STATE ZIP / 3 <br /> Mailing Address ifDIFFERENTfrom FadlityAddress a/) / <br /> Mailing Address City SEP 2 9TW08 =m <br /> ENVIRONNIENT HEALTH <br /> THIRD PARTY BILLING INFO: Completeif Billing Party is different from Property Owner or Facility Operator idenAfiedabove, <br /> BUSIIIE4 NAME Attention:were Of (optional) <br /> Mailing Addra46 // PHONE <br /> ONE AL S7 �ZZ/ <br /> CITY STATE CI ^ Zen ?S 3S/ <br /> w.vv,.rwrw�..ecec foorr fees and charges OWNER FACILITY/BUSINESS HIRD PARTY BILLING <br /> Ril]nNr..ANn CONfP IANry APRNOWI cnr.MVN: I,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that call PeRAm'F££s, <br /> P£NAtn£S,ENPORC£ MrCHARG£yan lAr HGORLYCHw M.asocbsNd with this operation will be billed tome at the address identified above as the AceorwrrAnnwnw,c for this site. 1 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 C0Usr V 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 facilitylsite address,I hereby authorize the release of <br /> any and all results and environmental assessment mformad to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ae soon as it is available and at t same1 m t is <br /> Qrovided to meor my re esentat e Bell <br /> APPLICANT NAME SIGNATURE r 7 <br /> TITLE DRIVERS LICENSE at s L/ <br /> (MtOT000PY REQUIRED) <br /> Apprrwad BY Date Auuansting ONice Pmcesan9 fomPlated By <br /> 29-02-002 Apri125,2003� 1 <br /> �O\O <br />