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QP <br /> EC �VEDD <br /> San J04uin County Environmental Health )artment <br /> DATE �l7 �'� MASTER FILE RECORD INFORMATION ""MFR"_ _ <br /> 5... mer.:ane CtJA uar/1wi i \ <br /> OWNERID71 CASES P �;t' )�V <br /> Eek �rilc, �11T5 i, <br /> OWNER FILE <br /> COMPLETETHEFOLLOWINGPROPERTY NFORMATION• GrECKrF OWNER C"' RENnyONP1L WrAt EHD <br /> PROPERTY OWNER NAME /J 1..� Polow all i6 /x.77 M / <br /> `r First MI C "� {,/LB3! Y/ V <br /> BUSMLS9 NAME r Qp h e�/.o v O er� ` t L /'� SOC SSC/TAX ID 0 <br /> Owner Home Address r ! (� J („� DRIVER'S LICENSE 9 <br /> City SYATE Z.Ip <br /> Owner Mailing Address J.'550 <br /> HQk 6 r e / J <br /> V <br /> Mailing Address City /I a(sl Cwt �'rc/�mel-�-r• I U State/ H Zip qG7/__lQ <br /> CORPORATION❑ INDIVIDUAL❑ PARTNER51-11P❑ FED ANIENCY❑ QTMEtijz/ <br /> FACILITY FILE <br /> FACnsry ID,V oo 6d <br /> CROSS REF ID# �FACCQVNTID JF 6 O ^ t7 <br /> S �O M (^ <br /> COAPLEWMEFOLLOWDVE BUSINESS .1 FACILITY I SITE DyFoRmA77oN., <br /> Is this a NEW Business LOCATION not previously regulated bV ttie ENvmoNMENTAL HEALTH DEPARTMENT? YEe ❑ Nag <br /> Is this an EMSTING Business LocmoN but aaNNEwTYPE of regulated <br /> y� /Business? YFS ; 'yN/o 11BUSNESS/FAULMISITEAM <br /> NE P;1 1' Q` e—! Ce +ers Ir iaw 1G.t 3 I r l953155 <br /> Srm ADDRESS 1099 8 J Hat-tall Road Sum# BUStNM PHONE <br /> cm Frenck, carnp <br /> STATL CFS zip 5 _ 3 � <br /> Baan or SuPuRvz5aR Dismcr LOCATION CODE KEv2 <br /> Mailing Address/fVhWfQENrhom ft6ifyAddresw SNS Long S Attention;or Care Of(optional) <br /> r( jP Aa FGJ, V <br /> Malling Address City Kh O xv l it O STATE 7—N zip 00/ <br /> ECOIE <br /> LAIPN t# 1 C� COMMENT; <br /> THIRD PARTY BILLING INFO. Comp/ete/f Billing Party iS differentfrom Property Owner or Facility Operator eent1fledebove. <br /> BUSINESS NAME Attention;orCare Of (op&,ow1) <br /> f t LvT "T 1�-ftV(:�L C GN i�2S L(-� C�'T!�'�ILW� f�"IJILINS <br /> f4alltn9 Address <br /> 5-5-Cc5 L-V"-J A S 1z Ci A D PMONC <br /> C" V Aj0 vl c�� STATE -TA) ZIP <br /> Accc--A-- for fees and charge6 <br /> OWNER FACILI7YI5U9INE3S HIRE PARTY BILLIN13 <br /> BILLING Atin JU'AFT IIurr ACKNOWI FUQti 1.r; I,the undersigned Applicant,cerdf;that I am the 04stcr,Operator,orA&ih6q-izva` IBCIU of this Business,and I aC00w e s PE:&WTFees, <br /> PEN.ecrres,E.'vF000VdFVTCJfARets und/or HOURLY CNARrss associated with thir operadon will be bitted to me at the address Idend led above as the JLQ2 7daaa=for this site. I also certify that <br /> all Infbrmadon provided on this application is true and correct;and that all regulated activitien will be performed in accordance with all applicabic S&.N JOAQVIN COUNTY Ordinance Codes and/or <br /> Fitandurds and STATE:and/or FEDERAL Laws and Rcltdatloos.As the andcnigncd owner,operator,or aecnt of the proper*v located at the above fadlityriite address,I herein,autbarize the release of <br /> any and all mutts and environmental assessment Infbrmation to SAN JOAQCTW COVISTY F.NVIRO\WIEYI AL HLUTH DEPARTp1L\-I as soon es It Is avdiloblc and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME C6(t'f1C1rIa /f, _I tf_PLEASE PRINT SIGNATURE <br /> TITLE Seng pr .E ^Asn gY DRIVER'S LICENSE# ��r. 71V <br /> (PHOTOCOPY REOUIREDI <br /> Approved BY Data Accounting OMke Ptwegsinp Compieted oy Date <br /> 29-02-002 April 25,:003 <br /> 7 n ',a )T-CT )nn7 J f1PI:J TCQ7nCh•XP J ninT I nny I ct,inn I n1T J <br />