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Z002 19896 ON P1/X,L1 7T :60 OOJ 20OZ/80/£0 <br /> 03/07/2005 13:48 FAX 209 946060 y(./ V3. 7-0 <br /> !0 V✓. l V ®002 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MA=RFILE RECORD INFORMATION FORM <br /> SNwrp ScpromsmRFJID Uss Dav ONNGa IDR CAsi! <br /> COMPLLTGTHEPO C WINO BUSIN OWNER PILL' <br /> FS$OWNER/NPOfM/ATION; CHBbf II OWNER[i/aPrlM"LYQV r1Le ptYN EHD <br /> RUSIN 6tS <br /> Oww-K NAME PHONR <br /> Fltet N/ LaM <br /> N[S4 NAME(II deM.,dapn Owner Wme) 5'a 9.e OrT.M ID/ <br /> - <br /> OWNER HOME ADDRESS r '� <br /> City V a. S <br /> OWNff/ LING AtbRE$9 Ot(BPhpnl Mom Owmr Addie..) Asernlen nrGnd <br /> MAWNC AOORtlf Cllr STATE � <br /> Tri[OF OWNERSInr: <br /> CXnwtiATON❑ tNoiwpiPAl❑ PAt.MtnpnP CI d ❑ ".WAvs'nty0 lrrlTa [v r tT*IInO <br /> FACIUTY FILE <br /> FAalm 1100: CoOWNERIl p• ArCOLWTID# <br /> COMPLETE 7WR OLLOWING QUSIN ESS FACILITYINFOMwartON: <br /> Is Ih5 a New Ausine LOCATM10r VK�F I1pt Prtviti MgUka Md by the ENUAON4m+ KAT DernRTMFN/f7 yes <br /> b W5 en Will NC 6W IRM L.00 cvi ovt a him Trm O!m2m, 0 6uOMe�7 YES ❑ 102 <br /> 3U9fl.SSIFACLLRTNAME(nKwA ECOCaiM✓bta MArEMn NCALTN FEWAM <br /> l� 4SUS� vu WVL_J .1 UL� <br /> PACIu-rYACoiiwss1ro: W H.AA]eaa/em UrrptboeV auuW 6UiINi{p PNCNi <br /> a3s37 <br /> COY err .a MOeu tiro- lice tlwC titimoAmi $TA ZIP <br /> 0 4w <br /> HCAM OF[SLt"I''LMLN <br /> YSOR DSTmi La noN K6v't KTY2 <br /> NIA N0 AD l TO� /DI M1it(it o*FE l F AAhvl ApdnUM wCMe Or <br /> MAll1NO AOORPSs C1W $ <br /> TATE' <br /> eA <br /> SIC COOL: APN b GOMitNn <br /> drrnrryr en oFC r-.efe"and Chargoo: OWNtA ❑ FApuTy1DuSINESS ❑ <br /> R.�L�r.LCIr aNn rn..e.aAnn' n[+ --+[s vie.—. ,[, qi0 underfi6iied Aplltivint, certify that 1 am the Ownw. Opx aror, ar.4rrhor4W.lterir of[Ois <br /> IIuel.cu,And I ae4nmrlodCe that all PsNMrr FEET, Pr xrrm,ENroaerWr TC�AAc Andror)70,,Mr CI UCAr ae.00il$d with this Opcntion will be <br /> b:llod to me a1 tho Addron idon0fled ahoy m Pt.ACQ2tZ[wnna=for this tlte, 1 also urpty dial mil information poovldod on this applient;on n true <br /> Ana correct; And that all regulated Activitip will be performed in accordance with all appliolble SAN JoAQvov Cotj� Ordi"tirm Cede and/or <br /> S ndards n STnTC and/ r 'm.RaY.Ln n R uIAQOnB <br /> A MNAM 1' NATVNO• <br /> areae Mer p <br /> Tme! PPL N A OATr 3 1 o DAivnrs LICstuc p <br /> Approved Ry Date Accounting ORim rroeeaalny CompPeted RY Dote <br /> A PROGRAM(RNID 48-02-0434 Pin10 Or WAT£R S�'aTtm il!"D 46-03-0043}form count be CpnpM.d inr trach EHO r gula' '--.rANon ai I O(;�pLq eltcapt <br /> UST Program rya.SWRCR forme) <br /> F1410415-02-031 <br /> 10192003 Pon <br /> Z *d TOTB-E9b-SZ8 uo.leLIS e <br /> BT CBO SO BO -+eW <br />