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REif) <br /> San Joaquin County Environmental Health DepartmentVF-O <br /> qA PR REENR1� <br /> DATE 0?� 2J J .1 MASTER FILE RECORD INFORMATION "MFR" 2 2006 <br /> gHAOFn ARFAC FAR FHn iiCF r1Ni v OWNER ID# --TCASE# PE t A.1�LV <br /> //y- Y <br /> OWNER FILE r1L/ <br /> CHEcKrF OWNER CURRENTLYONFmFwrrH EHD ❑ <br /> COMPLErETHEFOLLOWING PROPERTY OWNER INFORMA770N; / <br /> PROPERTY OWNER NAME PHONE <br /> First M/ LastSOC <br /> l 1 J <br /> BUSINESS NAME I_ I �/J ((�v(-(�'�`U,� SEC/TAX ID# <br /> /�� <br /> Owner Home Address C 1 1' DRIVER'S LICENSE# <br /> City STATE ZIP <br /> n� <br /> Owner Mailing Address 2 J I r�`I r�S I �'v` �/�• 2— <br /> Mailing <br /> Mailing Address City :�a �(�� .C_I S L State + Zip <br /> TVeF r1F nwrm smm l J <br /> CORPORATIO!�:gf INDMDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FFAaLm ID# <br /> CRoss REFiD# ACCOUNT ID# INv# <br /> COMPLETE THEF0110MG BUSINESS I FACILITY I SITE F <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 <br /> BuslNEss/FAalm/SITE NAME �, l•t� P(U eS ( j <br /> �,�� ��oc� �yc �� e_.e✓ tII V VSITE ADDRESS IJ SUIrE# BUSINESS PHONE <br /> Cm Tf L� STATE / ZIP l 3 U <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYI KEY2 L J <br /> Mailing Address/fDIFFERENTfrom Fac///tyAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Comp/et /f Billing Party is different from Property Owner or Facility Operator identified above. <br /> rttion:orCare Of (optionsQ <br /> BUSINESS NAME S (— //A/'f/ - �CaV A PtteT ,���A� <br /> Mailing Address �.'P A v PHOlN9Q f 6 ) 9 / <br /> CITY STATE ( ZIP J_� <br /> -0 <br /> Arr awmADaRESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> llu uNc AND roMFi.tAN(' ACRCNowt.FnamFNT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PErvneTTEs,ErvrORcenfErvTCruRces and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the A CO mrL'rApDRF�c¢for this site. I 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 JOAQUIN COUNTY 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 as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME ��i t�_ KAa_Sa PLEASE PRINT SIGNATURE <br /> TITLE /v DRIVER'S LICENSE# <br /> 111 (PHOTOCOPY REQUIRED) <br /> Approved By Date Accounting Office Processing Completed By Date <br /> 29-02-002 April 25,2003 <br />