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San Joaquin County Environmental Health Department OCT 2 7 12008 <br /> DATE �o/Q,�d� MASTER FILE RECORD INFORMATION "MFR" Ely iIRGARIWIPMKH <br /> l "^/ PERPJ!MSERVICES <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV <br /> nl2/✓ O\L7 V Y! <br /> OVMER FILE <br /> COMPLETETHEFOLL OW/NG PROPERTY OWNER/NFORMAT/Ow CHECKIF OWNER CURREIVTLYONF/LEW?H EHD <br /> PROPERTY OWNER NAME /) PHONE 54 e r �s <br /> First MI `7 Last VVVV <br /> BUSINESS NAMEXasilq <br /> /l yP /v �` SOC SEC ITAx ID# <br /> Owner Home Address DRIVER'S LICENSE# <br /> City STATE ZIP <br /> Owner Mailing AddressJ <br /> Mailing Address City //O oe/ State /fAr Zlp F7,230 <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OT- <br /> E <br /> FACILITY FILE <br /> FACILITY ID# �(�bbkq <br /> CROSoREFID# ACCOUNT ID# P�D p 3'k3 69I"V#COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE/NFORMAT/ON' <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ N�i� <br /> IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ Nq,� <br /> BUSINESS/FACILITYISRC� . <br /> E NAME l � �Q,,(,`/ -r&-- <br /> SITE ADDRESS JJJ [ e K $URE# BUSINESS PHONE <br /> 70 <br /> CITY w STATE ZIP <br /> FBIDARDOF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address/fD/FFEREAfTfrom Faci/ityAddress Attention:or Care Of(option#/J <br /> r �✓ ss <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner orFacility Operator identified above. <br /> BUSINESS NAME Geo se ••�ver P ,� / _Z,�L Attention:orCare of(optional) 45, �c /'W. 4-4 <br /> _T Mailing Address n�J �'a rC PHONE <br /> CITY �.J�/Q( -yt� STATE V ZIP <br /> F77TAIDDR///EIII ss for fees vand charges OWNER FACILITY/BUSINESS THIRD PARTY BiLLLIING <br /> 13u,L1�C svn('ovtrt.tnnce:�cl:�ovcl t7x:we�7: 1,the undersigned Applicant.certif. that I am the Owner,(Iperulur,or a l uU(nri;,crl.Tent of this Businea., acknowledge that all ': ill iittrs, <br /> PFNAI.nEs,E:NIORCEMEA1('I1IRGES and/or[/III RIA CH IROES associated with this operation it ill be billed to me at the address identified alwve as the ACCUI:\I ADDRESS for this site. 1 also certih that <br /> all information provided on this application is true and correct:and that all regulated acticitics will he performed in accordance with all applicable SAV JOAQI I.N COLNTS Ordinance('odes and/or <br /> Standards and STATE and/or EE.DERAI.Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facilihdsite address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAV.IOAQLIN('01 NTN EN%IRONNIENTAI.HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my represent tive. <br /> APPLICANT NAME PLEASE RINT k . SIGNATURE <br /> TITLE DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIRED) T <br /> Approved By Date d Accounting Office Processing Completed By Date v <br /> 'Q-u? 10/12/07 1 MASTER FILE ECO D-GREEN <br />