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San Jojin County Environmental Health *artment <br /> DATE (V25-leF MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> stM9Ea.Aseaa TOS Exa uaeo owxER.wrCABER UNIT IV <br /> OWNER FILE <br /> COMPLETE THBFOLLOWLNG PROPERTY OWNER hwoRMA TION: CRccrlF OWNER CputNverrzrovvx.Ewfm EN(D} <br /> P11Weary OerelBe NAAe PHONE <br /> First MI test <br /> 4 r 1—'� <br /> y <br /> BUBtNESNAaR .�'pG�G.Y"4 O,Yn'♦� t-('mu Sl i� --a--IAV Q-S7brt SM twn iu <br /> Owner Marne Addroas �(b{ Q � ,v vt'� `J't". jf {2-+C7�1 OmvErt's Llct�sseR t(,/.� a.,� ' <br /> CRY <br /> �Y'Vs (n„�,,,� BTATE / 7JP CvG-CD/ <br /> ONrnrMWepAkiraas ! ` <br /> MtuRrq Address CRY Shite _ eL z I <br /> r"Fe”Combats" <br /> coaPogATwn❑ INDNtDUAti17 PARYNEWIP FED/bBCY[]❑) bntm❑ <br /> FACILITY FILE <br /> FAcluW ID B CRoss REr ID s <br /> ACCOUNT IDM INM <br /> COMPLETETHEFouoWING BUSINESS I FACILITY I S—/NFORA/ATKTN,• <br /> Is this a NEW Business LOCATION act previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES / No ❑ <br /> ee <br /> Is this an E%I"No Business LOCATION but a NEW TYPE of regulated Bueine ? YEs f9J No ❑ <br /> IsuawEealFAenm/SrrE NAME VQ.L(y„vl J`@r evLl <br /> - <br /> &M^°° Z. Sun <br /> g#[� a�Lm s� . <br /> 1< S(� SaEr BUBINI'dB Ps� 14 <br /> IgNE } w 1 <br /> CITYG..`�TiD Vt- STATE ,—,4 Zv <br /> 00AR0 or3twegwsoq DtsTnlcr LocanoN CODE KEYI KEv2 T V O <br /> Malling Address XD/£FERENTfimsFatn#Iy^1Wresy ANen. :or Cam Of tWrSNrref) <br /> f <br /> Mailing Address City a Is <br /> STATE Zip <br /> SIC CODE APNR CotamENr. <br /> THIRD PARTY BILLING INFO: C/OMP1 ate ifBiliing Party is different from Property Owner or Facility Operator identified abov^e., <br /> 6USME99 Nam d�O 1'\JCS f\J' <br /> IA.Qi VIQ�,Nt K ->P-YV l L.J�S Attention:orCare 01/opfFwta/J',/vin't <br /> Mailing Addreta / V41�l {1�, ascn uenl,t..� 7C 7, GGy�/o/! p3^ <br /> Cm' �j'L{t P.r^ l- f r'r'e [� STATE <,+ Zm Q7 Y 2 U <br /> ACCOLINTADDR£SS for fees and charges OWNER FACWTYBUSINESS THIRD PARTY BILLING <br /> Rn.L1Nc AND 711171 rssrt 11x17-171717 "the molorogned Appteanq certify that 1 am the Owner.Otrentmr,or AarhariZed.fgeed of this Bse <br /> ushe ,and 1 acknowledge that all PRRMn'FE,,, <br /> l <br /> Pyr ru v,EAH x,.t wjj.AR9Le and/or RODRGY CRARti T Asswuned with this operation will be billed to me at the address identified above as the A(T'(It1WADDRR.FC for this Site I mile certify that <br /> all informatim prmLlci nn Ibis application is true and reran,,and that ail regubted medvities will be performed in accordance with all apPlica We SAN JOAQVW C(ANIti Ordinance Codes and/or <br /> Standards and S7Art.and/or i}:DERAL laws and RegulAtens. As the undersigned ownre,operator,or agent of the property heated at the above forility(sia address,I hereby authorize the release of <br /> Any and ail resultsmud environmmhd assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL Ii NAI.TII DEPARTIAJ IF.M1'T ass ae it u avails k and at a same am it u <br /> provided tomm.rnryrepreaeandve B +I <br /> APPLICANT NAME h1L,. ,� r/I /r S Pin SIGNATURE e ` <br /> TITLEr•rtv�LG 6„A�l(. Q DRIVER'S LICENSE/ <br /> tPHOTOCDPYgECUIRED) <br /> Approved DY <br /> Accounting Omce PrexemF,p Completed ay ASVFR FILED <br /> 29-02 10/12/07 ORI?-GR—EL,v _ <br />