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Fr9A:PAflISH & SMALL 2099520250 09/03409 16:06 #993 P.00210Dr0 <br /> San Joaquin County Environmental Health Department <br /> DATE za AugnBt 2009 MASTER FILE RECORD INFORMATIcki�iE�VIEDREEN FORM <br /> $" RE EN0L5a°N`" OWNERIDe OWDDIb315 SEP 0 4 2 09 UNIT IV <br /> oWNee"""a ENUIRO Li <br /> COMPLETE TNEFOLLOW/NOPROPERTY OW NER INFORMATION.' AA�'TzroaPAePmN E"o El <br /> 1'ROPIXTYraYMER IVATae rHONE. <br /> nrar MI fast <br /> BUSINESSNAME Community Bank of San Joaquin Soc Sec/TARIDN <br /> owtrer"nne Address 22 west Yokuts Aveunue DmNfR-SLI SE4 <br /> City Stockton STATE CA ZIP 95207 <br /> Mailing Address City NA gtil}a NA Zip NA <br /> C.ORPOaATIONIKK INDWIDUAa❑ PARPNFR$HP❑ FenAOENar❑ DTHER❑ <br /> FACILITY FILE II pp <br /> 1Q <br /> FAgimlDx Ffl�� Clitiss ReFl�S' ACCiwNTIO6 .. t\�OZS�bO I"y" \ 13 "A 5�) .... <br /> COMPLETE THE FOL L0W/NO BU51NESS I FACILITY 13 IT L INFORMATION.' <br /> Is this a NEW Business LOCATION net previously regulated by the ENIARONMERfAL HEALTH DEPT.? You ❑ No ER <br /> Is this an EGsTING Business LOCATION but a NEW7YPE of regulated Business? res ❑ No [3 ' <br /> BD91NEa51FACnDYIStmNANE Vacant land APN141-090-37, APDT141-100-26, APN141-090-38, APN141-090-40, APN141-090-39, <br /> "APN141- - 1 an APN171-090-36 <br /> SITEAe,nou; 1943 East Fremont Street stirreil Duodena Pnaree <br /> Cm Stockton STATE CA ZP 95205 <br /> or6eruMCeno.rt LoonnoR cease Ni4a KM <br /> Mailing Address YDIFFERENTilvs faaWyAdabesa NA Attention:or Care Of(ap8'wla) <br /> Mailing Address City NA; ' STATE LP <br /> 'SIC Cooe APNY COAtNrxxr <br /> '-THIRD PARTS BILLING INFO: Complete/fBllling Party Is different from Property Owner or Facility Operator identified above. <br /> 'eusmeeo NAME Parish and Small ,Ota Professional law corp Att,,Wm m-onum Or(ialin a/fwilliam Parish eeq. <br /> Malling Addreoo 1919 Grand Canal Boulevard PHONE 209 952-1992 <br /> CRY Stockton Wale CA ZP 95207 <br /> gctbUNTAOOR<3u forfessendcharges OWNER FACILITYMUSINESS THRTDPARTYBILLHG <br /> B11,LING AND�OMPLIANCL ACRHOwcsocanyiv 1,the underelgull Applicant,cestllythat lam the Owner,OpeMor,ord(whorit dAg"affhu Buslueas,andT aelmowlalge that allp£ n-F:PES <br /> .PRn'AEiim,ENmACEMPATCfua aad/or Buuur Cuneusmocktcd with Miraperadon will be billed lo meal Me addrraa identilla above m the ACrn ADaxEas[r this alto Ialso uAry that <br /> 'rail iofarmadoa provided os Mie spplicatloa is true and eanrech and that all regulated activities will be performed In accardaace with all applicable SAN JOAQUIN Cidw YOtdinanee Codes and/or <br /> jStaadadaand STATEand/ar FeD LLamand Reguladem.Aa the undenignedowner,openme or agent Ortho property leaded at the abovefacility/riteaddno,I hereby anthorire thereleau or <br /> �oy end aB Hsu1Ls and eoviromlrengl aueismevl lafarn�adoh to SAN dOAQU1N COUNTY ENVIRONMENTAL HEALTH DEPAR M S.u it I va sad a same dme i[x <br /> !pro,dded to me or my repro, m've. <br /> APPLICANT NAME /{/�yy, VSPIFgeEPelNt SIGNATURE s <br /> TIRE y�� DRr"'SLICENSEN <br /> (KRYr000"Roat Rml <br /> ApProvnd By Dole Accou�dg Office lteceaeilg Completed 6y cele <br /> T9-02 I0/12/07 MASTER FILE RECORD-GREEN <br />