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Nc, l—N D <br /> SAN 4 2012 <br /> San Joaquin County Environmental Health Departmentst-"N,JcaauI I COALTY <br /> DATE '7111 <br /> Fn�VIRONME SENT <br /> � '7/// MASTER FILE RECORD INFORMATION "MFR" GREEN X111 i DEPAR <br /> SHADDn AREA9 FOR EUQ2ff ONty OWNER ID# 12,13 <br /> X IJCASE# ( V UN■ ■ IOWNER FILE <br /> COMPLETETHEFOLLOWINGPROPERTY OWNER INFORMATION.' CmwKIF OWNER CuaREvr[yaHr'reE'wirH EHD <br /> PROPERTY OWNER NAME PHONE <br /> First Ml L.asi <br /> BUSINESS NAME I� SOC SEC/TAX ID# <br /> Owner Home Addresa DRIVER'S LICENSE# <br /> City STATE ZIP <br /> Owner McRtnp Address <br /> Melling Address City z7 7-'0C !�Ay� <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ Q FEDAGENCY❑ OTHER El <br /> FACILITY FILE <br /> FAawTrID# 21 L^� CR088REF ID# INV#0537I <br /> L- -7 �l� <br /> OLL / <br /> COMPLETETHEFOWING BUSINESS <br /> Is this a NEIN Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT,? YES ❑ NDA <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ ND <br /> BU8INESSIFACILITYISITE NAME .,n t., �. <br /> SUITE* BUSINESSPHONE <br /> SRE ADORE96 � , C•lit L r C i !'„'C� •-J-�!' —S ��(� <br /> CITY _ -y/— STATE ZIP <br /> FB.... <br /> OF SUPERyism DISTn= E LOCATION CODE KE" T_ KEY2 <br /> MaIIng Address IMIFFERENTirom FacAtyA€ddiess Atterilion:or Cara Of topLbnap <br /> Mailing Address City STATE Zip <br /> 91C Cope APN# (2 Z COMMENT. <br /> THIRo PARTY BILLING INFO: CompleteJ✓ifBilling Party is different from Property Owner orFacility Operator identified above. <br /> BUSINESS NAME 1 1 i/-� ! Adention:crCars Of(opte-flit/ , f <br /> h�vrLY1 C I Zj S;�i f ='1 f C��v c' G'y <br /> Melling Address 5-A j ^FC (` IL i^ [_ .� PHONE,.. `I l C(_� �` 5 G� <br /> Cm r'U / /7 STATE /JJ ZIP7 <br /> Arrpunty naW.5 for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> SRL INC AND CostrLIANa.ACAN0WLEn(:A1PNT: 1,the undersigned.Appk'e a,certify that I am the(hwrcr,Operalnr,orAuUtnrized Apart of this Business,and 1 acknowledge Sial ail PRRmuftEs, <br /> rEmALTzEs,ENFURcEvEM'Cr"nuEc andiur EIOURLYCnARGet'assovated with this operatian will be hiilod to.—i e,c add,ess identified ahove as the ACC'ULgaA tinRt.CS for this tic I also certify Lhut <br /> all information pruvlded oo this appliention is trur.and corner and That all regulated activities will be performed in accordance with all applicable SAN JDAVUIN COUNTY Ordinance Codes and/car <br /> Srandarde and STATE aodlor FEDERAL lases and Regulations Aa the undersigned owner,apcsator,or agear of the properry located at the ahove fadlitvhitc address,I herehy aatharve the release of <br /> any and All results nod olviroomentad asse memt informLtitm to SAN JOAQUIN COI.WF1'ENVIRONMENTAL REAL771 DEIThfENT ae soon as it is avilitaMe and at the some time it is <br /> provided to me or my representative. <br /> PLEASEPnINT SIGNATURE �(Sl o� Uj� <br /> APPLICANT NAME �q;�.�o ��IZ't�Q <br /> TITLE ` i \ y��� � DRIVER'S LICENSE# _ Q <br /> SCP Gkbt' O� \Qhs O °- Vx CA I l U (PHOTOCOOYREOUIRED) J <br /> Approved By Ootn Aceaunting Office Pmcesslr•p Completed By Date J 2 <br /> 29-02 10/12/07 MASTER FILE RECORD-GREEN <br />