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San Joaquin County Environmental Health Department <br /> DATE iz July zoio MASTER FILE RECORD INFORMATION "MFR" <br /> SHADED AREAS FOR EHO UM ON, I[h0Vt1ER ID/ CASE/ UNIT IV <br /> Ot�oo 1`l� <br /> ONINER FILE <br /> ComPLETE f HE AxL owwo PROPERTY OWNER INFoRA►a 77om- CHEcas OWNER CfAPnEwnravFelefmw END <br /> PeoP OWNER NAME DEBORAH COOK PRONE (209) 957-4565 <br /> First Ml Last <br /> BuswEss NAME MINATRE-COOK PROPERTIES Sac SECITAalON <br /> Owner Home Address P. 0. BOX air-1V C1 r'10 ORWR'sLICENSE/ <br /> city STOCKTON, CA STATE CA Tjp 95208 <br /> owns runs Address <br /> Mailing Address City144Y- state ZIP <br /> CORPORAIONImo <br /> T <br /> ❑ INDIADUAL " PARTmasNIP❑ FED AcxN El On1ER❑ <br /> FACILITY FILE <br /> FACILITY ID iCROs REF ID/ AOcouw ID/ <br /> 11UD oyKg 6b3 65221 2fl5-�3 <br /> COMPLETE THEFOLLOw)NG BUSINESS/FACILITY/SITE INFoRmI now <br /> Is this a Nm Business LO Tiohi not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YEs [ No 12 <br /> Is this an EXISTING Business LO TION but a NEW TYPE of regulated Business? rias ❑ No M <br /> BUSMESSIFACILOY/Sn NATE MINATRE-COOK PROPERTIES <br /> S-AODREss 230 NORTH STOCKTON STREET SurrE/ BUSINESSPHONE <br /> CrrT LODI STATE CA Lp 95240 <br /> BOARDOFSUPEIMSORDMTRILT 0 LOCATION COOS O� KEr1 KEr2 <br /> Mailing Address ifDIFFEREAfrfrwn FacAWAddreas i7 b Attention:Or Care Of(opbonaf) <br /> P. 0. BOX 9ATO <br /> Mailing Address City STOCKTON STATE CA ZIP 95208 <br /> SIC CODE =1 <br /> APN/ CoaMENT: <br /> TNIRo PARTY BIWNB INFO: Complete dBilling Party is different from Property Owner orFacility Operator identified above. <br /> BUSINESS,NE Attention:orCare Of(opbanal) <br /> Mailing Address PHONE <br /> Cm — - STATE LP <br /> Ao9quATAO0RM for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> RIL1 ANG AND COMPLIANCE ACKNOWLEDGMENT: 1,Me andetSigned Apphemd,ferlify that l nm the(heel Operator.lir AaMoriLL✓Agent of ds6 Basamm,and I selmowledge Mat all PFR.N?FEF_Q <br /> P£NALHF_s,FNFO"FNTCHAwfFN and/or HOURLY Cn iu;its aasoeinted with this operation will he billed to nM al Me address identified above as the ALr OL'NTADURFCS for this site. I also aerfify Mat <br /> A]information provided on this application u True and correeh and that all regulated activities will be performed in accordaner with all applicable SAN JOAQUIN COUNTY Ordinance Cada and/or <br /> Smodards and STATE m Wor FE DEMI.laws aM Re UNfi m. Aa the undersigned owner,operamr,or agent of the property located ae Me above facility/site address,l hereby authorix the release of <br /> any and ail resale and emironmeoml assessment information m SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT m swn m it u available are at the same time it is <br /> provided In me or my repreunmtive. <br /> APPLICANT NAME DEBORAH COOK PL .--PRINT SIGNATURE,* <br /> TIRE OWNER/PARTNER DRIVER'SLICENSE/ <br /> �O IPNOTOCOPY REQUIRED) <br /> ed <br /> ApprovBy Dean / t) I A Nldng Office PnneesaW C ,deted By 1 I Dem —t b <br /> 29-02 IOAPIUT "'""'-^^" ^^^ ------- <br />