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San Joaquin County Environmental Health Departrl��t.IFLIIV��TH <br /> D"'a Z9 SSP o4 MASTER FILE RECORD INFORMATION "MFR" PEF�MI <br /> � I � <br /> BxaAEAMTAsiaa EHO VSEONLY CWNER ID# CASE# - UNIT IV <br /> OIYNER FILE COMPLETETHEFOLLOWINGPROPERTY OWNER INFORMATION; CRE H/F OWNER CumEwLroanlFwim EHo <br /> PROPEATYOWNEq NAME PHONE 2. 09 '7 — W7r5m4 <br /> c F#s1 M! ( Last <br /> BusfNrsa NAME ! ll •\ s aGK O EO[C✓ D QVL� 0.(�.yN,P{l�,}- �nsEntTAzlD# . baoo43 <br /> OwnerHomJJeAtltlamomt �.S sen I ONveses cEMEIF q <br /> ° STD(.IC CA STATE / A!'1 ZIP ISoZ, <br /> Owswr Mellla# Addacea �Q. clove, lu <br /> MAIIIng Address City stats. ZIP ��--{{ <br /> - CONIUMTiON ❑ lemVmarm. 0 PARTNERSHIP❑ Fan AGaNCT ❑ OTN" Wc ikkj <br /> E <br /> s <br /> - FACILITY FILE <br /> igCRTn.ID# CgasSHsPtO# - Acdaearin# - INV# <br /> COMPLETE THEFOLLOW/NG BUST NESS / FACILITY I SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? Yes El No EA <br /> I <br /> to thla an EXISTING Busineae LOCATION butes NEWTYPre fregulated BDsinaea? YES ❑ No 5 - <br /> BUSINEWFACIL 16ffENAME <br /> SREAnnRES1s I � gy T, j � N L ( re SUREN Bu9INEQSaPNONE <br /> of" S+O (, tc r° UA I � l J -'v afATECA LP 7SZOZ <br /> BOARDOFSIRY-aVISEROMMOT LOOnnONDObE KWI Kett "l <br /> MailingAddreas MD/FFEREWTrromFml/RyA�ss Attention: esr Caro Of (opUbsuall) <br /> ,SSEM yA-k2nmP'r4 Sire Se, e. Isoo <br /> McNhg AdsUa9e 011y s r STATE C A AP q ft I I <br /> In F0.hG e 1 <br /> slocaug APNff - GOMMEM: - ' <br /> THIRD PARTY BILLING INFO: Complete lfBillIng Party Is dffferentfmai Property Owner or Facility Operator fdentlAed above. <br /> BUSINESS NAME Attention: orcare Or (of flonR9 <br /> � i' Q sins 1201 <br /> MMIIIIg Addroea (.]'SSSu ' Q, IE00 PHONE tI1S - 95'S - 9o4ti <br /> ow SO. h rPLLp1 �eSC � STATECA ZkP99III <br /> ACcotJMrAnnaEsa forfess and nharges OWNER FACIuTYBUSINEs9 THIRD PARTY BILLINtl <br /> EIIa.ING MVD CON@LWNCE Acmow womENT: I, fine undersigned Applicant, eorllrythet I nal Ills 01571oy Operator, or Aag1e14Tedelgedl of this Emblem; and I ndlnowladgo that all PL»AnrFMI <br /> PDLIWr£S,ENfr1RrA.1TPhT CruxCrs and/or HOURGYCruRcrs'esmdntnd with this operation will be bitted to tie at YM address identified above no iheAcconeaAl10RPS.r fm' tills site, I also carNfy flint <br /> all inPornmban provided on lhh oppileation Is true and correct; mW (hut v0 regulated activities sell be performed In accordance with Oil applicable SM30AITMCOUfers' Ordbanee Codas and/or <br /> strudel its and STATa and/arlemmut Laws and Regulvtlons els themrdorsigned owner, opefnbr, or agent of the properly lurnhd nt thevWvc fudlttylsl(end<Iress, Ihereby nulM1orize the release of <br /> any and all results and environmental nssessusent information to SAN dOAQMN MUM ENVIRONMATAL HEALTH 1) e ' 'f4{I;N1 us as as It Is available and nt the snake time It is <br /> provided to me or my representative. J - <br /> PL EPRIta <br /> APPLICANT NAME �t� �N.1fR�T�11 , s1�,, I � F 910NATURE <br /> TITLE ' 1,011.1 laRIVERs8 LIGEN.E \Nj � <br /> kn� is <br /> T. <br /> pv <br /> Approved By Bab Acoountl Utica Procatidna 0ompleled By nate <br /> 2902 1WI2/07 MAS'UR 1711,E IMCORD-GREEN <br />