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San Joaquin County Environmental Health Depatment <br /> DATE GREEN RM <br /> MASTER FILE RECORD INFORMATION YTMFRr' <br /> mF Fun evn. OWNER To# UNIT IV <br /> GSE# <br /> OWNER FILE <br /> COMPLE7E INE FOLLOWINGPROPERTY OWNER INFORMA mom OIE[a'>F OWNER CuRRENnymmFisorrN,END <br /> PRWERWOWNERNIIME /J,Cr�S L06- S// f "�GNC(-/ PHONE <br /> Y yFirirst Ml Last <br /> BUSINESS NAME D..4 SOC SEC/TM ID# <br /> Owner Horne Address 5'600 CidR/SMAN �O,glj DRIVER'S LICENSE# <br /> City <br /> T ALY STATE C,4 z, 710 <br /> Owner Mailing Address e"C/ a/�,�y� <br /> Mailing Address City •75 S ryiia+ state �P <br /> TVFFnFfvWNF01mV <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGEA! OTHER❑ <br /> FACILITY FILE <br /> FACII-Tre ID At CAM REF ID# ACCOUNT ID# INV# <br /> COMPLEZE 771E rOILOWNE SUSI N ESS I FACILITY I SITE LNFoRmA 77 N• <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? yes ❑ No <br /> Is this an OUSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No,Ysl <br /> Busimm/FACBSIY/SHE NAME <br /> SHE ADDRESS <br /> SUIn# Buswrss PHONE <br /> Cm <br /> SPATE ZIP <br /> BOARD OF SUPERwsOR D6rrazu LDUTION CODE KEPI M2 <br /> Mailing Address ifDIFFERENTfror»Far✓/ityAckomss Attention:or Care Of(Dptrolw/J <br /> Mailing Address City <br /> SPATE ZIP <br /> SIC CODE ppN# COMMENT: <br /> THIRD PARTY BILLING INFO; Complete if Billing Party is different from Property Owner or Facility Operator identfled above. <br /> BUSINESS NAME V�/' �OrQi9� <br /> � � V/0A1 Attention:[scare Of (optioneQ <br /> Mailing Address � 0�0 <br /> O /47-r-W*Y 04lif� P1'24 YL— SU <br /> IE-15-O PHONE �0 <br /> Cm S,9 EAtro 9 833 <br /> for fees and Charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> B r : 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Bred7 end I aclmowledge that all PERMIT F As, <br /> PENALTIES,ENFORCEMENPQRARGES and/or HOumtYQGRGES Associated with this operation will be billed tome at Me address identified above As MN <br /> e ACCVUTAnnay CC for this sits. I also Certify Mae <br /> a8 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 PCDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site addreso,I hereby authorize the release of <br /> any and all results and environmental assessment information To SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon u it is avails le and at the same fime it is <br /> provided to me or my representative. <br /> APPLICANT NAME ,4eI 04#11V4A/DYKr SIGNATURE t <br /> TITLE Ul/I fn�lG ,1 6�jp �t (j <br /> KKJ �£c-e'v �IHN/y Va'/� DRIVER'S <br /> Monstoct,y LICENSE <br /> Ch /T 3 D 740 <br /> Approved By Date Accounting Men Processing Completed By Date <br /> 29-02-002 April 25,2003 <br />