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San Joaquin County Environmental Health Department � ��� <br /> IM <br /> TE} MASTER FILE RECORD INFORMATION ""MFR" Mj� � 04 <br /> L LILY <br /> r c.,n DCF(TNI V OWNER ID# GSE# `` rL <br /> T H <br /> ES,,r_ tJ <br /> OWNER FILE posslez-y <br /> C� <br /> ETE THE WINGPROPERTY OWNER INFORMATION; CHECKIF OWNER CURREvn YON FILE WITH EHD ElMPLFOLLO <br /> 2o <br /> PROPERTY OWNER NAME <E U,� [- PHONE IL 7 C <br /> First MI Last <br /> BUSINESS NAME A L/j G�G K l•(n/t C(<r'b6 SOC SEC/TAX ID# <br /> r1 4!L <br /> C Amer Home Address PO S O x 575 <br /> DRIYE R'S LICENSE# <br /> city STATE ZIP <br /> 01,111ner Mailing Address M <br /> Mailing address City State Zip <br /> CORPORATION❑ INDMDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OrH ❑ <br /> FACILITY FILE <br /> FEID# CRoss REF�D# ACCOUNT ID# � INv# <br /> MPLETE THEFOLLOwrNy BUSINESS I FACILITY I SITE INFORmA710N. <br /> Is this a NEW Business LOCATION not previously regulated by the ENvIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an E)GSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No 7 <br /> BUSINESS/FACILITY/SITE NAME ALr tC 3 ,eU^m U <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> o o F o o za r6-.K7015 <br /> Cm <br /> Loy <br /> ' �X4 `J 51Y1 <br /> BOARD OF SUPERVLSOR DrsT>sICT LOCATION CODE KEPI KEY2 <br /> Mailing Address rfDIFFERENTfrorn FadlityAddrecs Attention:or Care Of(optional) <br /> Mailing Address City <br /> STATE ZIP <br /> SIC CODE APN# �7 G-D7�OO/ COMMENT: <br /> THIRD PARTY BILLING INFO: Comp/ete if Billing Palsy is ditl`erent from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Atbention:or Care Of (optional) <br /> EP 6FO MY". 0A 5fy ZE0 FICA) <br /> PHONE <br /> Mailing Address <br /> � N. J'A c-01�. 3 .20 - -0L< 0 <br /> CITY � <br /> d/vvr//urd/1nDFK for fees and charges OWNER FACILITYBUSINESS THIRD PARTY BILLING <br /> 1111 1 TNG AND Comps I&U:F.ArKNOWI.FDC.MFNT; 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERAf7T FEES, <br /> PENAL77ES,ENFORC'EMENTCHARGES and/or 1I0URLYCHARGEC associated with this operation will be billed to me at the address identified above as theACJ1.1I DDRFSC for this site. 1 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,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRON'RIENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. PLEASE PRINT <br /> APPLICANT NAMESIGNATURE <br /> TITLEn DRIVER'S LICENSE# <br /> PRO FC°`7 6�64:5>61S7 (PHOTOCOPYREOUIRED) Ay65973t <br /> Approved By Date Amounting Office Processing Completed By Date <br /> 29-02-002 April25,2003 <br />