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04/013/2003 14: 31 2054683433 FIFTH FLOOR PAGE 04 <br /> ERM <br /> ,wa,'!' -.Agai, <br /> 0-1 <br /> 214 <br /> N <br /> FORM <br /> MASTER FILE RE00RD INFORMATION <br /> 7. ir UNIT IV <br /> W t9 01 (i-64, oVINER FILE CHECKiP OWNER CuRNSAfrt,r ON FILE WITH EH 0 1: <br /> COMPLETE THE FOLLOWING SLISINEW OWNER ImFoRwrtojv: <br /> ----------- <br /> BUSINESS I A(ee PACNE <br /> OwNgzz NAMZ '------------------------------------------= <br /> ............... ........... <br /> BUSINESS NAME(if nMmit(mm 0wrwr Name) i 3cc Sfc f TAX ID 0 <br /> Ay <br /> i STATE 7-j" <br /> SQ C e Q,/.'r1 e--,Ie <br /> OwNER MAjUNGArCRESS (tY01FFEREAiT*vm Owner Address) Adentiw:or Cw*of <br /> 11t*il4FkC Addrfts City stau ZIP <br /> CRANRAnQN Q INOIWOUAL-k PARTNERSHP LOCA�AGFNCY❑ COUNTY AGENCY 0 STATE Ar,m— 19gPAa4N0y 0 OTH <br /> _4 <br /> L/ - <br /> FACILITY FILE �4 �V 1 2,. - <br /> " OR <br /> 0-041 <br /> ComPLETETmEFoua~ BUSINESS/ FACILITY)SITE INFORMAT(ON: <br /> 13thin cihlew&minem LOCAT)ON not IsfavicLuty regulated by the ENVIRONMENrAl.HEALTH OFY040M Yo N, U <br /> is j1j3 an E.45rlmc-8"irm0.7s LOCATION buta New TYPI1 of ragult;d t3usirleee 7 yo ❑ NC <br /> SILISINIE35IIIIIAGIUTYISTE <br /> SITE ADDRESS 3 VITF t, EkJ3INES3 PHONG <br /> CITY STATV Zip <br /> Ma&ig Addro=WDIFFEREVrftm XicAVt/AOWN= i Aftntion:or Carl Of(QPVQe-Q <br /> Marling Addrtu C* STATE <br /> F- H <br /> A;tc� 1 HE AS <br /> THIRD PARTY 3I LING IM'OPXATIDM-- COMP16tV ff Billing PgrtY is different from Business Owner IdenWWSbOve. <br /> Susses NAME <br /> MisaisM Addrows <br /> Crryo TrALTIC ZIP <br /> r <br /> 4GGQSl <br /> QjEjELF forfa"and charges OWNER FAcuTy/Busmss T.-oD PAim SLLm <br /> I,tht-ndM1gMJ Appl;CUL.ratify that i aoi the oww.4vitwe, this B%54106*1 "I-I-Owl-drc th't all <br /> p—vuffr FZA Pz-z"= EN")tCx&fw-T CuAat="d/op Kat,,nLr C=xczs stui2led sash this operation will be ballool wase at the 2d1r=3 W-urwd aW,. w the .40-70C <br /> Appty-5w for this site. I also certify that 34 idorwaLion proykf&d an this application is teas and c6rfsd: aad that all rraLim-d activities will bepe-rOrmcd In accordamce with Ab <br /> applicabit 5,A.N JoAQucm CuVNrr 0,rdismacp Cedes awVor St=darh—d STATE&ad/or FEDExL LaL%g mad"ut:dimc As thd sudwsiped owner.operator,or zVol Of the ProPfM <br /> located at j!w above NcjUtyi;lt;; addresa. I hereby authorize the rclo:awq of my sad all mvdlts sed environmqnW usnument infu-21iob CD SAN JOAQUIN COUNTY <br /> E.NN-TRONVENTAL HEALTH WYMON u won as tt Is avahabIc aad;af the sim time it is peovidcd to mv,or my reprts"umive. <br /> APPLICANT NAME St"ATURE <br /> TITLE -1 se, /,>-a- <br /> w <br />