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1 D�ETMDD <br /> San Joaquin County Environmental Health epartment <br /> DATE y j�, � MASTER FILE RECORD INFORMATION "MFR" SEP &2&FoRm <br /> ENVRONM�IyT�H�EALTH <br /> Su.ncn.oc.cmevuwmnu,v OWNER ID# WE# P RMIT/UNMO IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOWING PROPERTY OWNER INFORMA770N: CHEarrF OWNER CHRRENnrcwf zEWHN END <br /> PROPERTY OWNER NAME PHO' <br /> First MI Last <br /> BusnffsSNAHE /#MCO 2F,4L rY C o✓z P- -roiLKTO j Soc SEc/I"ID# 50 o301 C7(S <br /> 3 <br /> Owner Home Address SZ 3 8 MAu 2 +,- 7–,r4 4-ve: DRIVER's LIaNsE# Q I p <br /> city CMI Z. STATEzip / S / O O <br /> Owner Mailing Address ✓ ID <br /> Mailing Address City Sf State Zip <br /> Tris ru nua <br /> CORPORATION IIDIwDUAL❑ PARTNERSHIP❑ FED AGENCYOTHER❑ <br /> FACILITY FILE <br /> FAaLnir ID# CROSS REE ID# AmouNT III# INV# <br /> LETETHEFmLOWING BUSINESS I FACILITY I SITE rNFORMA770N., <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an E)(IS TING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No 7 <br /> Busuass/FAQLtre/SnE NAME f — <br /> Lo <br /> SAE ADDRESS /C// 6:l 5 I /�--910C C.AVCF- SUITE# BUSINESS PHONE <br /> CITY J T-0v�C(4/77-r) STATE (-14— ZIP 9 52/ C <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEPI KEYS <br /> Mailing Address WDIFFERENTfrom FadlttyAddr Attention:or Care Of(optional <br /> )Attention: <br /> L' Z-4'E E i1cf- N/S <br /> COMMEM: C <br /> STEbMailing Address City = � <br /> U C) <br /> SIC CODE APN# z <br /> ITHIRD PARTY BILLING INFO: Comp/eteif Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NMIE Attention:orCare Of (optional) <br /> K(- Z^"C <br /> Mailing A9/d✓dress^,,{'^(7�].l, X32 rL occ C nl-cct) . Le, ArD CLS 7 8/ <br /> cm • /V'rl w 1 V/`J STATFr. �j ZIP C (1S6 4J <br /> erm..am Rnnnc«for fees and charges OWNER FACILITY/BUSINESS HIRO PARTY BILLING <br /> RIP T TNG ANTI CnMPI InNCR A1aNny1 inCMRNT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT F£EF, <br /> PENALTnec,ENFORCEMENTCHAaGEs and/or HOURLYCHARGES associated with this operation will he billed tome at(headdress identified above as the 4rcO lNTAnURFCe for this site. 1 also certify that <br /> all information provided on this application is true and correct;and that all regulated activide,will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDEml,Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,l hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT s soon as it is available and at the same fine it is <br /> provided to me or my representative. ',C(�/JJ/)( <br /> APPLICANT NAME .�Zc -tel ��Q- �h PRwT SIGNATUREA7N— <br /> TITLEDRIVER'S LICENSE# <br /> Approved BY E J r Date q - 1 AcmunGlg Thrice Pracesirg Completed BY _ <br /> 29-02-002 April 25,2003 <br />