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San�quin County Environmental Health�oartment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SHAGEO AREAS Fmr END USE ONLY OWIER IW CASES UNIT IV <br /> WOD15 S12 1 <br /> OWNER FILE <br /> COMPLETETttEFOL LOWING PR0PER11Y OWNER/NFoAwAnoty Cwmff OWNER cfARrfemraxruEwmf END <br /> PROPERTY OwrIERNArE � X,-a f tr,e, P14DNE C <br /> Fat MI last <br /> BUSINESS NAPE BOC SEC/TAX ID>E <br /> LI SJ/E CUELD £tN Gc�R <br /> Owner Home Address s �}St,e l.iCc S/,C£B7 '� DRIVER'SUGENSEA <br /> chy S)9 Av ?UJ STATE/ a Zip zJ,// <br /> i <br /> Ovewr Idaiirg Atldrosa C'� <br /> Mal"Address City gyps � <br /> CORPORATION❑ INonnousL❑ PARTNERSHIP❑ FEDAGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FAcIUTYIDA 66 17 CROSSRwID/ AccoucrIDS l.` INN "0a-9 <br /> CoAmvrTHEFOLCow mG BIUSINESS I FACILITY I SITE/NFORN477ON.- <br /> Is this a NEW Business LOCATION not Previously regulated by the ENVIRONMENTAL HEl1LTH DEPT.? YEs ❑ No ❑ <br /> Is this an EXWTING Business LocATION but a NEW TYPE of regulated Business? YEs ❑ NO ❑ <br /> SUSINESSIFAciL /SRENAPE <br /> SITEADORFsa BUTTE/ BUNNESSPNOHE <br /> CITY "I'an T STATE G/g LP <br /> BOARDOFSUPFRNSORDISTRICr LO TIONCOGE KE11 KEY2 <br /> Mailing Address IVOIFFEREATfio n FadFtyadaless Attention:or Care Of IePaL.d) <br /> Ma114g Address City STATE LP <br /> SICCoOE APN# CorNENT: <br /> THIRD PARTY BILLING INFO: Complete dBilling Party is different from Property Owner orFacility Operator identified above- <br /> BUSINEss NME .7 Attention:orCam Of toobbiral) <br /> �vJ d-nQ 1"U <br /> Melling Address SUV N �Jt•;Eye o<n� f� :,9 '1.2 PHONE /d) 6 yci-J'S/J� <br /> CRY G Hi Cs4'6 6 STATE T / LP 60VI '1ry <br /> 6fdDPlEpQ'ADDaBss for fees and charges OWNER FACILIIYIBUsINESs M—lT'HIRD PARTY BILLING <br /> BILLING AND COb1PLIANCE ACKNOWLEDGMENT: L the undersigned Applicant certify that 1 am the Owner,Operolor,or Auctarival Agera of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALT/ES,ENttJRLEMENTCMAR And/or fIOURLr CNARGES assoctaftd with this operation will be baled to me at the address identified above es the AcrotwADDalm for this site 1 also cerfiry 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 looted at the above facility/sift address,I hereby authorize the release of <br /> any and all results and eavirm mental assessment information m 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 reprrsentative 1 <br /> APPLICANT NAME ,V ,.e �t CDl//h) PLEASE PRIM SIGNATURE cu, ,9 <br /> TITSSPK 1 V✓' IrJJ e LY /'Lf Lrt 4f2r. URIVER'BLI NBES 7� <br /> /PHOTOCOPY R[-0UIREDI <br /> Approved By Date Aeseanotmi,Olflce Processing Complated By Dale L/ <br /> 29-02 10/12/07 MASTER FILE RECORD-GREEN <br />