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<br /> DATE MASTER FILE RECORD INFORMATION "MFR"
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<br /> OUVNER FILE
<br /> CONFLETE THEFOLLOWING PROPERTY OWNER INFORMATION. prr[c.Jclr• OWNER CuaticnrcrorvrrcEwirt/EHD
<br /> PROPERTY PHONE/r- �p
<br /> OWNER NAME �•Z C.�� J v'cIJyIIPV'�/�f•"I4 C. ( '"
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<br /> BUSINESS NAME `may' ' -SOC SEC/TAX ID a y'
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<br /> Owner Home Address 3 �j ��36�mwr LA) a��r DRIVER'S LICENSE t/
<br /> 1 City g,ate. L � "—O , r_7� p, STAT A 1� 7.IPYr� �.+��
<br /> Ownar Mailing Addrol-a•+o
<br /> q-.,Maling Address Cit
<br /> State Zip
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<br /> CORPORATIOr� INDIVIDUAL❑ PARTNERSHIP t7 FED AGENCY CJ OTHER❑ 1
<br /> - f\Ao FACILITY FILE
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<br /> COMPLETETHEFOLLOWING BUSINESS/FACILITY I SITE INFORMATION.'
<br /> is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES CI No ❑
<br /> Is Oils an EXISTING Business LOCATION but a NEW TYPE of regulated Business 7 I YES C) No C1BUsINEss/FACILITY/SITE NAME ,Sh! ls-A-IC4
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<br /> SITE ADDRESS SUITE# BUSINESS PHONE
<br /> CITY TATE ZIP
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<br /> Mailing Address IfDIFFERENI rorn FacllltyAddress Attention; or Care Of(optlollal)
<br /> Mailing Address City STATE ZIP
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<br /> THIRD PAR-ry FILLING INFO: Complete if Billing Party Is different fro -roperty Owner crFacilIty Operator identiriedabove.
<br /> BUSINESS NAME Attention:orCare Of (optional)
<br /> Mailing Address PHONE J�
<br /> CITY STATE Zip DDD
<br /> -u _va�s� for fees and charges OWNER FACILITYiBUSINESS THIRD PARTY BILLING
<br /> BILLING^AND COMPLIANCE ACKNOtt'LFDCM F•N'1': 1,file undels(gncd Appllennl,certify lhnl I nm(he(honer,Operator,or rluthorhed rf8elif of this Itgsiness.and I ncknnlvicdge(hal all
<br /> /'lrrsn/n'FRrv,Prav,J7.7uty,L'NroRCRA17iN7'COdROBv and/ill'1[oUR1,1'C1/.IRraT I1130chled is'RIl(Ills ollernlloll 1vill be billed to Isle at IIIc address Identified above ns file 1ICG0I1N7,r1!IURF_ev
<br /> for 11119 site. I niso cerilry fhn(all 111fot'nlation provided UN tills liplAleallotl I.9(rile and correct,wild tont nil reg'lllllled nclivi(iea tl'Ill be performed ill licclirdlince tridt nil npplicable SAN
<br /> .IOAgtNN COIIN'IY Ordhlmlcc Cndcs and/lir S(andards slid STATF,and/or I EDF.RAI.i.nws and Rcgelnllnns. As Iflc undersigned owner,npernlor,ar ngcnf of the property locntcd al file
<br /> above rnelllly/site address, 1 hereby ae(horize Illc relense. of nny and fill reselfs and envlrnsnlcnlai assessment Inform0lon in SAN JOAQUIN COUNTY I;Nt'Ift0Nl)l ;NTAl,
<br /> I IEA[:1'I i DIVISION as soon as Ills nvallab(e and Mille smile Ilnle It Is provided to Ale or in),reprosenlnllve,
<br /> PLEASE PRINT
<br /> APPLICANT NAME JgmI-ra �. �C'rcji�SOII SIGNATURE
<br /> DRIVER'S LICENSE 11
<br /> TITLE
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