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n <br /> i a rD) <br /> E��LI�1i ,0 <br /> San Joaquin County Environmental Health Department SEP — a 2006 <br /> DATE "MFR" -,` <br /> 9 �� MASTER FILE RECORD INFORMATION MFR _ I JT HEA UH <br /> C—Fn,.a�.cona O--ER �if-11 J --FU N IT�i IV�v�c�s <br /> rLan uc�nrh r CASE# <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION: OfrcArrf OWNER CvRxeiv cronfnrwnR EHD t� <br /> PROPERLY o C NIVI& — _ PHONE G <br /> ,�� <br /> i First MI Last <br /> BUSINESS NAMEJ Z�� SOc SEc/TAx ID# <br /> awtaa�M T A4-IP r. < � r'-_-I:T- <br /> YER <br /> Address DRI 's LICENSE <br /> Sir- � <br /> city _S- _ sTA,E cA I zIP 9 s <br /> Owner Mailing Address (-.�/)0 —s t(} a /u <br /> Mailing Address City l ti CCJ' State Zip <br /> 7 r� A <br /> CDKPORATIONX, INDIVIDUAL-❑ PARTNERSHIP❑ FED AGENCY❑ On1ER❑ <br /> FACILITY FILE <br /> FACILITY ID# 9, 17 <br /> CROSS REF ID# ACCOUNT ID tt 31 ll INV# <br /> O LETE THE LL WING FOM TION' f l \ J <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YEs ❑ No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO_a-_' <br /> BUSINESS/FACILITY/SrrE NAMEl l ( c s <br /> Lu-r <br /> SITE ADDRESS ( SUITE# BUSINESS PHONE <br /> CIT S-CZG Y--T[,tU STATE CA <br /> BOARD OF SUPERVISOR DISTascr LOCATION CODE KEY). <br /> Mailing Address/fOIFFERENTfroTn fac llyAddreo _ Attention:or Care Of(optional) <br /> �{GG I'-12 Y. ,No Ajl,rvu TiZU L� iz`+= <br /> Mailing Address City S SPATE 21p G I <br /> SIC CODED t� � APN# I`i.5-a►o-o q COMMENT: �— / <br /> THIRD PARTY BILLING INFO; Complete if Billing Party is different from Propertyl Own4r orFacilityy Operator Identifiedabove. <br /> BUSINESSNAME Attention:orCareflf (antral) <br /> Mailing Address PHONE <br /> QTY STATE Zip <br /> AcwyAmAOAtEss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Ru h ivr.nun roani.ha�r.Ar•hevnvrhrneahrNr: I,the nndersigind Applicnut,certify flint I an,the On91Cr,Operann,ar Anlhorieed Agent of this Dusiness,and f ncknonledge that all PEA.1117'FEES, <br /> PIaA',ILT11::C,F-,vr-oACEaIE,\'7 C1+nAesr altlUof,//OiiALi'CIIAA(%fS igsoeillyd with this operation will be billed to tie at the address kientned Itbove as the ArrounrAnnRlieC for this site.I also certify tltat <br /> nil hdornhatiun provided on this application is hve and correct;and flint nil regulated nctiAties will be performed In eccurdance with all xispileable SAa JOAQUIN CUIINFY Ordinance Codes antllor <br /> Standards and Sr%TE And/or FFTEH.U,Lamand Rcguhdiuos. As(lie undenigned owner,operator,or agent of the property located nt the above racllih'/site address,I hereby authorize the release of <br /> any and till results and cnrlronmcntnl assessment Information to SAN J COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is a 11be and nt the same flint it is <br /> prodded b me nr roy represenlatvt. _ <br /> APPLICANT NAME -2I P SIGNATURE ` I <br /> TITLEl n u DRIVER'S(PHOTOCOPY LROUIRED <br /> Approved By ►`Date Accounting Office Processing Completed By Date <br /> 29-02-002 Ap6125.2003 <br />