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• r UU IrI�;��I� <br /> San Joaquin County Environmental Health Department <br /> GATE 0 g MASTER FILE RECORD INFORMATION "MFR" GREENFgR <br /> —� 1 2008 <br /> SHADED AREAS HD USLONLY OWNERIEN1b U�iURVf IT HEALTH <br /> IQ J�l(1n '1�T�� cASEa 0P <br /> OWNER FILE ES <br /> COMPLE/E THEFOLLOWING PROPERTY OWN ER/NFORMAT/oN. Onecx/F OWNER Cuaernzy,,, Newm/EHG <br /> PROPERWOWNERNAME 1 *5t II {''� I - <br /> CJe a V'.LI PZ--q-16-- <br /> Lost <br /> BIISINESSNAME U C (� `t ({`real M1 <br /> O CCL C G ( Soc eEC/TacIDC <br /> OvererHarle Address <br /> DRIVBYs LIOENSEI <br /> City <br /> p STATE LP <br /> OwnerMeiling Address y / C' ' h 1 K .o, on S+r4L� SLID & ► 00 <br /> McWng Address City { V,f4'T`r� Sole <br /> G-vi-T, q 574 7 <br /> CORPORATION INpIVIDWIL❑ PARNERBNIP❑ <br /> FeDAaEHcr� DsxeR❑ <br /> FACILITY FILE ' <br /> FAcu-ITY IDI 11 R� {{1 r cRoss.RER1oI ccourrttDl -�}- <br /> -'Mb gb til INV# (� :. { 7 k <br /> COMPLE7ETHEFOLLOW/NQ BUSINESS/FACILITY/SITE INFORMA7YON.' <br /> Isth is a NEW Business LOCATION not previously regulated by the ENVIRONMENrAL HEALTH DEFr.Y Yes ❑ No rj <br /> Is this an E)OSPNG Business LOCATION but a NEW TYPE of regulated Business? <br /> YEs El NO Ly <br /> BUSINE6E/FACILRV/Sf1ENgME <br /> SREA topess 8 3fn_ <br /> '1-I ,L f.Cc l SUREt/ SOSINESS PHONE <br /> Clry s T <br /> sTA-6A ZIP 152 <br /> 06 <br /> BOARD O'SUPERVISOR DISTRICT T - LOCATpN CODs Keri,_ <br /> }tEY2 <br /> Mailing Address NDIFFERENTbnsrs Foci/itvAdoi s" <br /> Attention:a care Of(optona/J <br /> Mailing Address City <br /> -- STATE ZIP <br /> SIC CODE � ll ppNl_ g <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from property,Owner or Facility Operator identifledabove. <br /> BUSINESS NAME <br /> R G p 'D 15 J� AttetlUtxg crcaeOf fscvsNJ <br /> eP <br /> Mailing Address ( USD M f. ,Acl- W U S O�-I n <br /> PHoue 510_ 7— l -320V <br /> C,. <br /> CITYSTATE G q ZIP <br /> 9 0 <br /> A092 NEA Inn�'t a for fees and charges OWNER FACILITYIBUSINESS <br /> THIRD PARTY BILLING <br /> nILLI f AND 0 ANCE A o L the undersigned Applicant,certify that lam the Oa bl,,OperD/ory OrAmenr/r,MAgem of This business,and 1 acknowledge that all PERMIT FEES, <br /> PEKILr1&S,ExrDRc6'sfE/fr CHAReEt end/or Novftyf,, G,,..iated with ibis operation will be biEW Iomeat(he address Identified-havensthe AtmuM'nd I acksforthissire 1n outSr shat <br /> all od2rds Andtion provided an this application u true and cometh sad that all regulated activities wen be performed in acronlance with ell applicable SAN JOAQutN CDUNrI'Orditunce Cada ami/or <br /> any IAds l re STA-reand oa%iVormnseRAO Leas and Regulations. As the undo AQned met,operemy or agent of the praperry located ar the above faeisSAN J AQUINRldress,t hemby 4-dies lee the release of <br /> any the all results and prearanmenMl assessment information to SAN JOAQUIN'COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a soon as it is awihble end at the same time it is <br /> provided to me or my represenmrive. <br /> APPLICANT NAME PI.EAseuS%S Nr4 $.W. O/�PRI UPpA <br /> t n Pill F n AT7 SIGNATURE ` J ZG-C•X//i`U'.�. / cAl <br /> TITLEDRIVERS LICENSEI <br /> S O i � <br /> _(PNDTOCDPY REDO REDI <br /> aspOved By Dote <br /> 29-02 Accountin Osice Proceselne Co \ <br /> 70/I2/07 mplelede Data <br /> MASTER FII& CORD-GREEN <br />