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i nt <br /> San Joaquin County Environmental Health Departme <br /> TE MASTER FILE RECORD INFORMATION "MFR" <br /> MAY �°'�C104 <br /> ALTH <br /> 00 la3q ES <br /> CASE# <br /> EHD„<c nwiv OWNER ID# L. t- L <br /> OWNER FILE <br /> CHEcKrF OWNER CuaRENrzrovFiu wrTN EHD ❑ <br /> COMPLETE THE FOLLOW - <br /> INGPROPERTY OWNER INFORMATION <br /> PHONE 20-7 <br /> PROPERTY OWNER NAME <EU,(v L <br /> First M/ Last <br /> / SOC SEC/TAX ID# <br /> BUSINESS NAME /� L3F)eo QUCw <br /> �1 DRMR'S LICENSE# <br /> Owner Home Address P0 8 v X 7 <br /> STATE ZIP <br /> city <br /> Lv ip <br /> Owner Mailing Address <br /> State LP <br /> Mailing Address City <br /> TT?FA f1l•: RG4'-7 <br /> INOMDUAL❑ PARTNERSHIP❑ FED AGENCY❑ DntER❑ <br /> CORPORATION❑ <br /> FACILITY FILE <br /> FAQurr ID# O 0 53� =C,-,�� SREFID# ACCOUNT ID# ODale q5 <br /> Itrv# <br /> MPLETE LL F MATT <br /> 1s 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? <br /> YES ❑ Nop <br /> BUSINESS/FACILITY/SITE NAME AL3 <br /> SUITE# BUSINESS PHONEG <br /> SITE ADDRESS I O f o o o ^ D -670 <br /> CITY `�SUPIERV.tSOR <br /> VC �csBOARD OF D15MCI <br /> LounDN CODE KEY1 KEr2 <br /> Atbention:or Care Of(optional) <br /> Mailing Address ifDIFFERENTfrwn Fad/ftyAddness <br /> R <br /> STATE ZIP <br /> Mailing Address City / MM <br /> SIC CODE APN# O5 n-07-W6 COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party /s different from Property Owner or Facility Operator identified above. <br /> Attention:orCare Of (optional) <br /> BUSINESS NAME FICA) <br /> Mailing Address � V Lvn 3 <br /> PHONE"O <br /> CITY TRA cyl <br /> zCaUATAQ29ccc for fees and charges ONMER FACiuTYBUSINESS THIRD PARTY BILLING <br /> ni,1 IN,AVD C'OMPt I1N(-F ArI(NOWI FnrMFNT: I,the undersigned Applicant,certify that I am the OKner,Operator,or Authorized Agent of this Business,and I acknowledge that all PE2+nT FEES, <br /> PENALnES,ENFORcEHENTCHARGFs and/or HOURLYCHARGES associated with this operation will be billed to me at the address identified above as the ACC'OLrLTTADDJLM for this site. I also certify that <br /> 30 information provided on this■pprication is true and correct;and that an 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 oU 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. PSE PRMT <br /> SIGNATURE <br /> APPLICANT NAME SjfY L4,E �F 'F .0 <br /> �Rc>�FN7 6E�LoGi <br /> DRIVER'S <br /> TPu�)TITLE OMUDA V I Sc <br /> 736 — <br /> S7 <br /> Date D <br /> Date Accounting office Processing Completed Sy . <br /> 29-02-002 April 25,2003 <br />