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San Joaquin County Environmental Health Department <br /> DATE or�nn, <br /> FORM <br /> 9/8 03 MASTER FILE RECORD INFORMATION "MFR" SEP IGBEEW <br /> RONM�NT liMo i <br /> OWNE0.ID# v <br /> <"•" ^ �..,Pun,.rn.,,. pW00I,.QS `"E# p RMIT! <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION: CHEoeZF OWNER CURRENTLYONETfE wmr EHD El <br /> PROPERTY OWNER NAME PHONE <br /> First I MI I Last <br /> Bug NEss NAHESOC SEC/TAX ID# / O_O <br /> kind 2Ej1LrY cof^a- , r�crro,j 32 tOU tO`l0G3 <br /> Owner Home Address 5-2, 3 a MSN 2A,-/TQ H�If L - DRIVER's LiontsE# <br /> City CM-A'f c EZ STATE r A`T Zip 6) 6 0 8 <br /> Owner Mailing Address / <br /> Mailing Address City S/}M E'— State Zip <br /> T os nw.. <br /> CARPOMIION Inomouu❑ PARTNEASNiP❑ FFD AGENCYQr11ER❑ <br /> ..// FACILITY FILE Hh^ <br /> FAaure ID At fi11/so lyt�I-) CROSS REF III# ACCOUNT ID# OV <br /> ��SfGf/�. INV# 44 \ O�✓ <br /> COMPLETEE �`LII LWW 1 rNFORM77OW <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an DnsTTNO Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No 1 <br /> BogNESa/FAauTY/SDE NAME C <br /> SDE AOOREss /6/6 <br /> ID / �� MHEY°L- G-/7 ." SURE# BUSINESS PHONE <br /> CHY 3 7-Or-e-,✓(o, STATE _ ZIP 9's-21c) <br /> BOAROOF$UPEAVLSO0.DISIRxR LtXADON CODE KEYI KEYZ <br /> Mailing Address ifDIFFERENTftotrr Fadiityelddtecs Attention:a Care Of(opoornaf) <br /> L L E D(7-f f/c ( nil S o(Z- <br /> Mailing Address City SS ^ !,CIA-141, STATE/ ,,t LP 9, 902_7 <br /> SIC LADE -' APN'T#`K �I COMMEM: f^YT U <br /> \ ,THIRD PARTY BILLING INFO- Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> �l BusirimNANE Attention:orCare of (optlonaQ <br /> Mailing Address 7133 CQ-,' - V"��itJ� . J(� �IrZJ PHOHF�z.� , TBS_/'>QO <br /> CITY <br /> • &'t%4x,/ V%`J STATE,.. �f�� ZIP 6) / S6 4J <br /> a ^^� ^a <br /> A^ rK far fees and charges OWNER FACILITY/BUSINESSLyHIRD PARTY BIWNG <br /> ^^ <br /> RIT F INC Also r r'r Aruvnwr vnr rarvry1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PER.mT FEES, <br /> PENALTfES,ENFORCL!VW1, RARGE9 and/or ROuurCnwGEs associated with this operation will be billed tome at the address Meadried above as the Arrnrt elnnRFce for this site. 1 also certify that <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 JOAQum CmnsTv Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment Information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT s soon v(it Is�available <br /> )and <br /> Jaatt the same�fitne it is <br /> provided to m oNT NAME <br /> my representative.APPLICANT to PLEASE PRINT SIGNATURE <br /> TEfLE URwOEOPYREOUIREOER'S LICENSE# <br /> IS2 G��-sn��6-,sT� � / /� <br /> Approved By� r / Date ( 7 Aanuntirg OlTice Pro essing completed By Lys Date .__t/7. a <br /> 29-02-002 Apni 25,2003 <br />