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San Joaquin County Environmental Health Department REClaym <br /> GFT9N FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" a 2008 <br /> _('NAnFn ARFAC FnR FHn IICF Om V OWNER ID# III <br /> O ` oO���o CASE# Lil�y HEA UP <br /> W OWNER FILE ES <br /> COMPLETE THE FOLLOWINGPROPERTY OWNER INFORMATION; CHECMIF OWNER CuRRENTLYONfILEwrrH EHD ❑ <br /> PROPERTY OWNER NAME % ' 'It)u)nse n cl PHONE <br /> First MI Last <br /> BUSINESS NAME SOC SEC/TAX ID# <br /> Owner Home Address DRIVER'S LICENSE# <br /> city STATE ZIP <br /> Owner Mailing Address <br /> Mailing Address City n State A Zip (�S2 <br /> TWF AF nWNPRCMTD / J <br /> CORPORATION❑ INDMDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID# ACCOUNT ID# INV# <br /> 60 MIDX03 �t <br /> OMPLM THE FOLLOWING BUSINESS I FACILITY I SITE INFORMA770M.- <br /> Is this a NEW Business LOCATION not Previousiv regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an DaSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FACDIW/SITE NAME 11OU0 And OWL <br /> SITE ADDRESS14- SUITE# BUSINESS PHONE <br /> CITY 11 r r y <br /> STATE n A ZIP /�5`3 <br /> �RDSUPERVISOR DISTRICr LOCATION CODE KEY1 KEY2 <br /> VJ <br /> Mailing Address ifDIFFERENTfinm Facility Address Attention:or Care Of(optional) K <br /> Mailing Address City STATE ZIP N <br /> SIC CODE <br /> F <br /> PN# COMMENT: <br /> 1 <br /> THIRD PARTY BILLING INFO: Complete if Billing Party Isdih°erentfrom Property Owner or Facility Operator identAledabove. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> l Qi e <br /> Mailing Address Poor/ PHONE.269-q( <br /> -q(e loo( <br /> CITY �`n STATE^ ZIP ^s�I!�- <br /> A/"lAitA(T 4DDREyG for fees and charges OWNER FACILITYIBUSINESS ✓fHIRD PARTY BILLING <br /> Rn.r.INC.ANn CnMPL,IANCB ArKNOwI.FDr.MFNT: 1,the undersigned Applicant,certify that I am the Nwer,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT REFS, <br /> PENALITES,ENFORcEMENTCHARGES and/or HouRLY CHARGES associated with this operation will be billed tome at the address identified above as the AXQUNTADDR Fsc for this site. I 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/s1' 1kddress,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAI EP as soo as it is availa le and at th same ti.me it is <br /> provided to me or my representative. PLEASE PRINT / <br /> APPLICANT NAME (RobeV,j 1..(O L*l SIGNATURE <br /> TITLE �/ DRIVER'S LIC SE# <br /> Y I o9 -NI OS I C-/t IPM (PHOTOCOPY REQUIRED) II <br /> Approved By Data Accounting Ofce Processing Completed By V� Date Z Z b QrS <br /> 29-02-002 April 25,2003 <br />