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07/28/99 08: 10 FAX 209 465 0631 FORWARD INC. vl002/0112 <br /> `r <br /> :��M�l, i�.�. ,�:: ��.ss�SA,����;����.�i. a.���►:����-�. :"' n;>., s r�;_:• r�eta <br /> bATIE MASTER FILE RECORD INFORMATION FUM tc�+oo�stREvt.,Foowr+.ATI <br /> I-AQ[L waGu UNIT IV <br /> i <br /> OWNER FILE <br /> COMPLETETHE_FO_LLOW/NGBUSINESS OWNER hwoRMATlOW" Ch'ECK'P OWNER CURKFNTLrOWF/LP-W/THFHO <br /> BUSINESS PHONE <br /> Owr+ERNAreE I` �1�.L� S[ �dY1 �.�. i=`lei ���G— �----------1 1,66_ <br /> 8u61NESS NAME(rf cfWYeraent from Owner Nerne) SOC rsEC I TA%10! <br /> �t E 17 7/3 <br /> OWNER HOME ADDRESS Lj q l �. ! a, DRi <br /> city - STATE/ �{- i Ijp r <br /> "VVyY` 11 �-+I 9sa06 i <br /> OWNER MAILING ADDRESS (lrD/FFERENTfrom t7wnerAddnss,r/ Attention:orCare of (Opftoraa/} <br /> t <br /> Mailing Address City Stat ! Z]p i <br /> - I <br /> PF Me 11NMCRCMIP- _ <br /> dRP_ ORwTIp;�e INDIVIDUAL❑ PARTNERSIUP O LOCAL AGENCY❑ CpuNTY AGENCY 0 STATE AcENGT❑ FED AGENCY❑ OTH t❑ <br /> FACILITY FII.I_ <br /> aAGiLia1�WA 00 <br /> i7gS 1D- "�7 rr tel' <br /> CoAfra-reTHE'FOLLOW/NG BUSINESS / FACILITY/SITE INFORMAT/ow <br /> Is thin a NEW Business LOCATloN not prevlauzly regulated by the ENMRONMGNTAL HEALTH DIVISION? YES ❑ Nn ❑ <br /> hithis an EXISTING Bunlne»s LOCATION buts NEW T'fp6of regulated Businuee? Yes ❑ No 0 <br /> BUSINESS/FAGILfTY/StTE NAME Former Del-ta- Pa a e.f Cpm ash U <br /> SITE ADDnERS <br /> - --i—iSTE M <br /> Bstrf POmE <br /> 4DISou* h LIINCOL� �VL � t <br /> -7 <br /> S-rbCk-hpwo t ' <br /> 9 ego, ' �CITY � <br /> :l��S.�,.t;1Zi�1'>y..�,.'J,�'y�7�"t7..�r'�p ��•'r.�'.�?�':9�. �`��� .�� '� .c» `•:ii" , .�:^ .>i.1.'.'• �l�.t. <br /> Mailing Address d01FfER,EN/T yens Fap�hy/!dd ? Attention:or <br /> �CllC4re Of LopiYorsa/) i <br /> T %Slj,SS C <br /> Mailing Address City ' STA TIP <br /> _ Stns k Fen ; 9SaC6 <br /> THIRD PARTY BILLING INFOKMATION: Complete if Billing Party /s different from business Owner /dendr7ed above. <br /> BU$INE59 NAME Attention:or Care Of (pp ...... <br /> 144,4 li�e <br /> Mailing Address PHOS <br /> e5{ Y•�r(A/2Ci'+ <br /> Ctl y LG a yL S V l .ice/ SATE ZIF i <br /> Afel'�u1y111/) for fees and charges OWNER FAC Lrry/I3usINEss THIRD PARTY BILI m <br /> 3144�:C n�'p S O+ITL(AyCE.�cawQwzgocMerr: 1.the undeRiened Applicant,csrtif that I am the LN—r,Opveior,or,ttutb—i-edAgry f of this Dwiness, and I actato "g: th■t:11 <br /> 'EAM/T Fe£S, Pr?vALTTES, E.'JFOjgcrW--NJ'CJdARCLS And/or NvuRLT CyARGES associaled will, this operation *ill be billed to me at the addrtu idenli(icd owte as the ;)GCOf�,f <br /> IDDRf S for this dta. I also certify that all inr6rmation pm0dsd on this application k Ince and curr.r:t.: and that all rrulated aetir(tios *,ill ba performed In aceordnncel-ith all <br /> applicable S,t.N JOAQUC7 CO"TY Ordinance Coda and/or Siand.rds and STATE and/or FEDEML La«s and Regulation& as the undon(gned ei mer,operator,or agent or the property <br /> Dcated at lite abo••e facility/site addret., I hereby authorize the release or anv and all -nulls and enoironmenlal ;,seasment lnrormatlon to SAN JOAQMN C01)1I1Y <br /> ri'4TRONMErfTAL HEALTH DIVISI aS sooa vis arailehlt and at the same time It is provided to me or my cepreaentx%lm <br /> Pt.BASE PRINT' <br /> APPLICANT NAME `� � ,L- ✓ SIGNATURE- <br /> TITLE <br /> IGNATURETITLE - / ORIVgR'S LICENSE f <br /> Pop lPMnYnrnpY HFatfigFol <br /> �'h✓.�,y1v `kn,-ff <br /> A�ikr�lLnting OHlti�'Iarod"T <br /> pV-�4tttpitt6iii�1►' ,c h..r�xNr veil,�-�. >, , <br />