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DATE E(M <br /> San Joaquin County Environmental Health Depart QkLe(a <br /> MASTER FILE RECORD INFORMATION "'MFR" V� II <br /> CHenFn eRFec Fog FHn ncF nmy OWNER ID# CASE# rr <br /> r r <br /> OWNER FILE pFk9!7-4'� MrRi ��k c <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; CHECKIF O NE tVYtYb�F y EHD ❑ <br /> PROPERTY OWNER NAME PHONE 31 — '7 7 / <br /> First MI ! Last ( `i f <br /> BUSINESS NAME 0`/I, avi SOC SEC/TAx ID# <br /> Owner Home Address 1305- 4 DRIVER'S LICENSE# <br /> City Z volt CA g� 0-Z/1STATE 7ZIP <br /> Owner Mailing Address /tom lcJ 77(/ <br /> Mailing Address City hL State Zip <br /> TYPE TIF nwNFR W TD D <br /> CORPORATION❑ INDMDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER SCC gyp,/ <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID# ]= I <br /> AccoUNT ID# INV# <br /> COMPLETE THEFOLLowiNG BUSINESS I FACILITY I SITE INFORMA770N., <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an EJaSTING Business LOCATION but anNEW <br /> ���TYPE of regulated Business? c YES ❑ No ❑ <br /> BUSINESS/FACILIrY/SITE NAME ro 0:5 p_�/ &6� r, 5C. <br /> SITE ADDRESS ?/. �•w V J�"'���(((///�A,•„r �M,^ i+ �VVV SUITE# BUSINESS PHONE <br /> CITY kc Ir STATE/1./) ZIP ` <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address JfDIFFERENTfrvm FadlityAddress t Attention:or Care Of(optional) <br /> 14 6wet <br /> Mailing Address City —/STAA ZIP <br /> SIC CODE APN# COMMENT; <br /> THIRD PARTY BILLING INFO: Completeif Billing Party is different from Property Owner or Facility Operator idend ed above. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> [Mailing Address / / PHONE l��— <br /> CITY " r r STATE (!", ZIP <br /> ArrwN AAn`n &w for fees and chargesaJ` <br /> OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Bn.t.rvc avn(nvtPt i.��cF AI KSntYt <br /> La <br /> �1FN : 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PER NIT FEES, <br /> Pr:vunes,E:vrnecEalsn'TCJJARCEs and or HOUR[YCJJARGES associated with this operation will be billed to me at the address identified above as the AccpvATADDRecs 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 SA:v 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,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DTMENT as Soo as it is available and at a sa a time it is <br /> provided to me or my representative. '7� <br /> APPLICANT NAME L)^,y1 "`� L� t SIGNATURE. <br /> TITLE / C/L DRIVER'S LICENSE# <br /> C"E(/ (PHOTOCOPY REOUIRED) <br /> Approved By Date Accounting Office Processing Completed By Date <br /> 29-02-002 April 25,2003 c6– S <br />