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San Joaquin County Environmental Health department <br /> OAS - <br /> MASTER FILE RECORD INFORMATION "MFR" GREEI�FORM 2008 <br /> UN ;':,1 wA�J � <br /> ENO O <br /> UN <br /> OWNERID# I 'CASE# 1Tt fY - ; <br /> L. <br /> OWNERFILE <br /> COMPLETETHEFOLLOWINGPRO IERTY OWNER INFORMATION: - CaecKl£OWNER CURREwTLYONF/LEHrrH EHO <br /> PROMorYOWNERNAME 1 -51 M VtP,, PNCNE <br /> (CaR4.A. IFirst AAI Last <br /> BUSINESSNAME V I / IJ `I/1\ GI�I l�.O k 1 G r Soc5Ecl7AzIO# <br /> C G <br /> OwnerRome Addreas DRIVER'SLICENSE# <br /> CRy /� BTATE DP <br /> Owner M.Ift Address (,/ / JA 1 ,^ SinU,�& 1V h D <br /> Melling Address City { D U ti L T I StabsGA Zip (.l 5- <br /> CORPORATION INDIVIDUAL❑ PARTNVISHIP❑ FED AGENCY❑ J Qna'x� <br /> FACILITY FILE -- - - _. -- - — <br /> FncIL ttID# CROSSReF ID# AeceuNilD# INy#` <br /> d ii _ L <br /> COMPLETE THEFOLLOWING BUSINESS/FACILITY/SITE INFORMATION.' ,,.�,,// <br /> Isths a NEWBuslness LOGATIDN notpreviously regulated bythe ENVIRONMENTAL HEALTH DEPT.? Yes El No ,CI <br /> Is this an E)aSTING Business LOCATION but a NEATYPEEE 01'regulated Busine1ss? Yrs El N. Lg <br /> SUSINESE/FACILMIST'£NAME S.i-o L k4 o n 1\CA cix GY <br /> SneADOREss 18 3 3L [n "u, 1 T �,CC ` SUNF# SUSINESSPHONE <br /> D C ��� O n Z� 'I STATE GA ZIP 5 O <br /> BOAflDdFSIIPERViSOR DISTRICT ' LOCATKIN C9hE �Ll„1 = ;#� tl V <br /> Mailing Address/rV1FFERE7Vrfrnrs FaeiWAddreae Adenden:or Care Of(opbbi a/J <br /> Mailing Address City STATE ZIP <br /> ------------- <br /> SIC 06DE - APN# - CmnaeNT - <br /> THIRD PARTY BILLING INFO: Complete teBiliing Party is different from Property Owner orFacility Operator identified above <br /> BUSINESS NAME A `1 ! q e_ I /�J }, Attention:wCare Of(options/ll <br /> Mar7lrg(A�ddrees l Urso 1m �r, ;^ w Gt S O J"I L, PHONE 1510- 2-32) <br /> 0- I'1 1 C� M rJ/l Ti STATE G q ZIP q 4h'9 D 1+ <br /> AOOOOWTA/maFaR forfees and charges OWNER FACILITY/BUSNESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersign W Applian,cErtify that I am She 0x.1,QW11or,or Au#roriuv(Agent of this Business,and 1 ockamldge that all PEM/rFEFS, <br /> PEKA1TIES}Eh'F0RCEaf£NTC11AFG&and/or RounrCTimca acsacinid with this operation will be billed to meat the address identified above as the ACCODWTADDRPS9 for this Site.I Sao cerfifv that <br /> all information provided on this appliadon is nuc sed correel;and that all regulated acfivitief will be performd in aceordance with all applicable SAN JOAQWN Courrn,Ordinance Code,and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations.As the undersignd owber,operetop or xgent of the property?..led at the above fadlity/Site address,I hereby aolhoribe tine release of <br /> any and all results and onvinatens al assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon ns it is available and at the same dmc it is <br /> pr"dd lD me or on,represeatafive. ry{� / /,,/ qp <br /> APPLICANT NAME -Lalli IIP �1 AT7fAI—LA1/?1F H-+PRL'IryI P'�'ytf„yT s�F V/,p +�SIGNATUREr�dn jJ L <br /> TITLE DRIVER'S LICENSE I '1 <br /> - IPuorocorvREDWREo_ _ <br /> A2Dale A e Org Ola P IIgCmoutheday Data <br /> 29-DD22 1 1010/12//07 MASTER FILE RECORD-GREEN <br /> 49 <br />