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San Aquin County Environmental Health Oartment <br /> DATE 3 - I S - vS MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> GWNERID# p, 8t��,�7 CASE# UNIT IV <br /> OWNER FILE <br /> C0MPLE7EmEFouowrNGPROPERTY OWNER INFORMATION; ORaraa OWNER CURRENnYON FrLEwII/f EHD <br /> PxtNRRIY OMER NAME MA,/-!kM LA(-i-i n P""E a09- 620 I <br /> 4m4i Lest <br /> Busaness NAME /I � (J ` SDCBEC/TAXID* <br /> Dever Horne Address \ 1 3Lo3 N `JaVIs RIO aDrairs"Lrcssilse# <br /> City Lod; STATE cfl ; g S a y a <br /> Outer Mailing Address <br /> Mailing Address Qty Shbe Zip <br /> � Ivasn.om.ra <br /> eoRposuvr xi INDIVIDUU. PARTNERSHIP❑ gn�asme❑ OneR❑ <br /> FACILITY FILE <br /> FAaLrrr ID# I( O (� CRo5S REF ID# Aoostrr ID# rl�43(L IW* /2I <br /> IS this a NEW BusinPSs LOCATION not previously regulated by Ifle ENVIRONMENTAL HEALTH DEPARTMEIM YES ❑ No <br /> IS this an EI(ISTiNG Business LOCATION but a NEW TYPE of regulated SuslnE5s7 YES ❑ No ■ <br /> BUMES$/FACIIIY/SILr}EN�nM\E P\QC A--�� �Q� `\Y� <br /> SITEADDRESS av'�s a� sem# BUSINESS PEImE <br /> CM II ,tel , STATE n ZIP <br /> q s a L\ a <br /> BOARD Oe SUseinrcrc$OR D6TRIa Lcx;xrl M1 CODE BMI KEY2 r` <br /> Mailing Address ifDIFFERENTfrorn FadffyAddres Attention:or Ure Of(opdpnaQ <br /> Meiling Address City STATE IID <br /> SIC CODE APN# COMMExr. <br /> THIRD PARTY BILLING INFO; CDmplete'if Billing Party isdilfeientfinm Property Owner or Facility Operator idendfiedabole. <br /> Sumnim NAME Attention:orCare Of (clobb l) <br /> KC En Ineec 6.ompor-t� ,4m Lem <br /> Mailing Address S (o C /'Q- 1 n pMxE <br /> OO J l_ Lane , <br /> Q n e S��I�-e A7o7-4k-7 - t-to as <br /> STATE CA z8 9 5 (o lig <br /> for fees and charges OWNER FACU-n-YIBUSINESS THIRD PARTY BILLING <br /> RnI nvn AND CnwevsrvrP errrvnw rnrnrevr: I,Ne undersigned Applicant,certify that I am the Omer,OLserwar,or AuMorined Agent of this Business,and 1 acknowledge that aU P£RAUT FEES, <br /> PEXuum,EN£DeCENEV'r CHARGES and/or HOURLYC",UNGEe associated with Oil,operation will be billed to meat the address identified above as the Ar eWdoouccs for this site. 1 also certify that <br /> W information provided on this application is true and correct;and that all regulated acdvitie will be performed in accordance with all applicable SAN JOAQUIN CDUNT 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 httillty/sim address,l hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to mr or my representative ,S <br /> APPLICANT NAME � my E . q Lej�(< Plulfr SIGNATURE <br /> TTfIE L /�V I T o(7IYf Q 1 / AJJ ��S DRIVER'S LICENSE If <br /> (PHOTOCOPY REQUIRED) <br /> Approved By Wb Accosting Office Pracessirg Completed BY at. —13117tosl <br /> 29-02-002 April 25,2003 <br />