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� nnVInF I <br /> San Joaquin County EnvironXDj11 �eLtFr hT <br /> DATE 5-lZ.}(0_} ant <br /> MASTER FILE RECORD INFORMATION A'MFRrr GREEN FORM <br /> ED IREDS In On <br /> __ OWNER ID# /S( CAsE# <br /> UNIT IV <br /> COMPIXIiEMEEO/IOWNGPRO PERTY OWNER INaR <br /> iMq-ON: FILO <br /> PROPERTY OWNER NAME CNecrr OWNER CLRaEwrzrowFse H�rx EHD ❑ <br /> PHONE <br /> First MI <br /> BIbIIi�NAME Last <br /> �} �oac-A, -,„- QartS4_ <br /> Owner Home Address - ,• ` �-r- / SDcSK/TAX ID# <br /> DRMR'S LJONSE# <br /> City <br /> Owner Mailing Address S. — STATE ( _I S ZZQ <br /> Mailing Address City <br /> .s.ars�^—�_' o_ State ZiP <br /> CORrORATION❑ INDMWAL❑ <br /> PARTNERSHIP❑ Fm AGENLy❑ .�.,r� <br /> OrtERriJ <br /> FACILITY FILL <br /> FAatITy ID# �O CROSS REFID# <br /> I t ACCOUMID# FNv# <br /> Is this a DU Business LOCAn----ON not Previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ <br /> Is this an DUSTING Business t.ounoN but a NEW TNo ❑ <br /> 'PE Of <br /> regulated Business? <br /> BUSaff$S/FAcaTy/$TE NAME 11 p YEs ❑ No El Wt <br /> SMADDREss 133zor� <br /> / E • Sk . 1'_.�. �`� SUIT# B115ef1ES5 PNDNE <br /> Cm LO dct-TavcQ <br /> sraTE� m <br /> BOARDDFStNERvaipt DDTRILT 00'`` LDGTroN CODE IQY <br /> �4 l <br /> � I IOv2 <br /> Mailing Address ifDIFFERENTinSm FadlilyAnig ess <br /> 0 �L�� aJ��l ��. S� ir�-I � _Atterltion:w Carea(optiplaQ <br /> Mailing Address City d ; <br /> SIC CODESTAT: Zge I S 'Z2(� <br /> APN#0 <br /> Tyn11G PAIttr BIWNG INPO; Comp/efe ifBilling PartyJ is di/ferentfrom Pro <br /> BUSINESS NAME Pefty Owner or Facility Operator/dentified above. <br /> Ne`+ a . A-14 S Gh A- kc-90 c . „\ c Attention:wCare O!1(000na) (� <br /> Mailing Address <br /> CIO-z-aO. t•Tbb F•Acc7 <br /> Cm lPtpNEL'10 <br /> STAT: ` 1'• ��Z�C] <br /> 'Por fees and charges OWNER <br /> FACILITY/BUSINESS THIRD PARTY BILLING <br /> Blumr:armC - I,the undersignedApplicant,certity that 1 Am the r)w"er,(Iermmr, <br /> PENA/,TEc,ErvFORCEA/Eq/'ClL1RGET and/or TOUPET CHeRGEs associated with this operation will be billed to me al the addressor thanzedAgem,of ide identified above as lthB erress,and'I acknowledge that all PE2v/T FEES, <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOA UIN � for this site. I e Cod. <br /> certify that <br /> any and <br /> and STATE and/or FEDeRA6 Laws and Regulations.As the undersigned owner,operator,or agent ofthe property located at the above facility/site address,lh repo ulhorize he ales a/nf <br /> any and all results and eresent tive. assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon a it is available and at the same time it is <br /> provided to me or my representative <br /> APPLICANT NAME .yl PLEASE pgpn <br /> SIGNATURE <br /> TIRE <br /> DRIVER'S <br /> LICENSE <br /> A0 � Date S C A00"art q Omro Ptom m completed BY <br /> 29-02-002-0022 Apr;l 25,2003 Dam 0 <br /> CONFIDENTIAL <br />