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u ^ <br /> San Joaquin County Environmental Health Department <br /> DATE &-7/jo <br /> MASTER FILE RECORD INFORMA-nON "MFR" GREEN FORM <br /> SHADETI AREAS FOR EHO USE ONLy OWNER IDO I I CASE N � UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOMW PROPERTY OWNER lwoft a Tim.- CmoxiF CANNER CURREAMLYONPILEWTHEHD Ll <br /> PROPERTY owNERNAME PHONE ,�5-355/3c, <br /> /'' First {.// M,l`r Lost <br /> SUMNESSNAME h*jW /� / / --- Soc SEc/TAx IDX -7- ��� <br /> Owner m <br /> HoeAddrees _000 (f444/� /7►,0L. DAMEeSLICENSEX <br /> Gh' ZIP <br /> r <br /> Owner Moslog Address /fA♦, � � <br /> Msllbt8 Address Chy 7}p <br /> CORPORATION IL hWry1DUAL❑ PARTNERSHIP❑ FED AOENCY El OTHER l FAGUTY FILE <br /> FAc1IJTY ID S CRoss REr ID aY ACCOUNT ID S INVO <br /> COMPLETE THEFmLomw BUSINESS I FACILITY/SITE INFORMAnOAf. <br /> Is this a NEW Businerss LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES (� NO E]Is this an ExisnNG Business LOCATION but a NEW TYPE of regulated Bushms? YES ❑ No ❑ <br /> ' SUSINEFSIFACILm/SITENAME ��umb u/L�d <br /> r �►r� / <br /> SrrEA=RREE�SSv>/7�14 I'Y HutrEIf Bu61N/mPHONE <br /> C'm ,///1'f/ STATE A.A. ZIP 95 3 7 7 <br /> ,/. (.� <br /> BOARD DF SUPERMISOR DIST/tICT �^ LrOOATION CODE 9�--F <br /> uJ Ker2 <br /> IAeitblg r IA.) <br /> -'001> <br /> _ >�m AV��! M n t /� W-7— <br /> FN <br /> -7 Aftentbn:or Ogre Of/opHnrwt) <br /> MaIIkIp Address Cky� (OQb� s 'i�{r�I/�K• ✓�d aJ rr f J JP1AJ Mo N STATE zw <br /> ISICCOOF `r" <br /> Co Tete ilfg-BVw G13 <br /> f` COMMENT <br /> THIRD PARTY BILLING INFO: illliing <br /> ! o <br /> Party is different from Property Owner orFacility Operator identified above. <br /> BUSINESS NAME AftenUon:orCare Of lbptbrm/) <br /> Melling Address PHONE <br /> C1rY STATE zip <br /> Aaxj&T nrua_o for fees and chargesOWNER FACIuTYIBUSINESS THIRD PARTY BILLING <br /> RILLING AND D COMmLANCF ACKNOwL£oCwKr: 1,the und elf Applicant, t I em the Onnner.Operator,or Aafkorated Agent of this Rusintm%eml I seMnowledl a that allYERMrr FRES, <br /> PENALMS,ENFi7RMWENTCRARr.ES asdisr HOURI.r CRARGr_A'aura fisted wr operation will be fulled to me at We addr ,identified above As tbc,(( frnTARDRCCc for this site I atw certify,that <br /> All information provided oo tbis application is true and currect;and that all regulated activities will be performed m accordance with All epphellblt SAN JOAQl1IN CUtRfr}'Ordinaner Cudes and/or <br /> Standards and SLATE and/or FWrRAL LArns and Regalaliam. As the and-sigeed owner,operator,or aCent of the property IoAAtod at the above faeilirylsiec address,1 boreby authorize the release of <br /> any sod all resrdti and environmental ssseutnent inhumation to SAN JOAQUIN COUNIT ENVERONMEN'TAL FFEAL711 DEPARTMENT as Roan as it is available and at the sale time it is <br /> provided to mr or my representative. � <br /> APPLICANT NAME C.��41 L?� P SIGNATURE <br /> / ' <br /> TITLE / D O <br /> '7116 <br /> 1/y) /��� ORIVER'SPUCENSE l <br /> �l'rO"°d ey Oste 71 1 6 Acoountinp Office Procauing Completed By JJ Data <br /> ?wtr 10112107 1, MASTER FILE RECORD GREEK <br />