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San Joaquin County Environmental Health Department <br /> DnpMASTER FILE RECORD INFORMATION 'dMFRyy GREEN FORM <br /> SHAOEDARIMPQRENDNSEONI.Y ORTNEp IDM LIoY1' CAM# UNIT IV <br /> Poo OVIMER FILE <br /> CoAnETFTHEFOLCOW/ATGPROPERTY OWN ER IAMRNA770w G9feowlr OWNER CURAomyoerllessom END <br /> S t <br /> PAopEanOWNMLNAME trboat <br /> /J fkdo,n /Las IES( <br /> BWytE86NAYe 7rhe ._ L C CV C) �� S BOconnr RID# <br /> Oeel•I Nana Address vir <br /> DRNPR'a LIDENsss <br /> Call, STATs ZM <br /> Owner Meftsi Addreaa <br /> Melling Address CltY Gulf A- aP <br /> — <br /> CDRPORATioN❑ INdv1DUPLLJ PARfNERBNIP FEDADMDY❑ OTNER❑ <br /> FACILITY FILE <br /> FACILMIDM CRose Rgr IDs Ixvk <br /> CowLETE m,-Fouowwna BUSINESS/FACILITY/SITE ImVFORfm rIM' <br /> Is this a NEW Business LOCATION notprevbusly regulated by the ENVIRONMENTAL HEALTH Dam? Yes ❑ No <br /> Is this An EePANO Business LD TIDNbuta NEwTYPEcf regulated 13ualness7 yss ❑ No <br /> SUSINESSIFADIunIeRENAME w(r <br /> SDE ADDRESS Sun# BUMNM&PNa <br /> CrM �( STA ZIP <br /> BOMtsweu➢ETrvISOR DaTplm LOPATION <br /> MCIO�D[f' KEr1 ' � NEr2 <br /> Melling Address NDATFRERrsam Facs%&Addr Su, 1\ _ ANenSoor n: Cera Of(opeonal) <br /> Aae, <br /> Mussell Address CRY � STATE LP <br /> 810Cooe APNs COMMENT: <br /> THIRD PARTY BILLING INFO: Complete ifBllling Party is different fronlProperty Owner or Facility Operator identified above. <br /> BUSINESSNAMe A6 Awle, <br /> Attention:orcare Of(apdonall) <br /> WMngAddress PNDNE �M,, <br /> Cin STATE ZIP <br /> ,AggNtIMAWIRSa furfees and charges OWNER FACILITY/BUSINESS TNIRDPARTYBILLING <br /> S O C b r AC Qw PN4 1,the undersigned Applunne,ardry that I am the elmarropoaror,or A.MorhodASmt of Ibe sudnae,and I aehnuwiedge that nil PARM/TFMI <br /> Pmwcner,BNPOAGEMEM'CpARGA4 and/or 11WN4.YC11AR &aeloelMd with this aperetlon will be Nlled to most the address Nenllgol above N Ne AEr'nirMADnnray forwitim.lRkotetfifythal <br /> an information Provided on thus spplicalion h true and carrecn and Wal all regulated aUh9Ms will be performed In accordance with all opplieabla Snit JOAQum Nuery Ordlnnn,,Coda and/or <br /> StanJnrds and STAG andlor FEDERAL Laws and Regulallom.As Ito undersigned owner,apenlon or agent of the property located at the Rbove foriliryhite nddren,l hereby nulhoria the Mas of <br /> any and all ..%and environmental aoressment Information to SAN JOAQUIN COUNTY ENVIRONMENTAL IIEAIATI DEPARTMENT as soon is it is available and et the rnme Nine D Is <br /> provided to me or my Mloruentaive. <br /> APPLIOANTNAME SF,Vilrsle,,tjidi ePLEASE PRINT fr SIGNATURE <br /> TITUS Y vSEc--rc4c.J er? II.C.f &&AAIp,l �T DRIVER'SLcENser <br /> 'fLa.T...wl C—..anew De_.arl.n...e_1 P_ L _!!:,F, LP rowTanew REOe,Rso, r <br /> -ppreyad By Data AccounUn9lellvA ProaeeenR Complelatl 9y ease �I <br /> 39(2 ICANO MASTER FILE RECORD-GREEN <br />