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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SMAOED SECrAYEfaRFlID U3f Ouv OwuePIDE IOU/ODZ/DLH CASES <br /> OWNER FILE <br /> COMPLETE THE EOLLO//W�I/A'ODUSINESS OWNER/NFOSAFARON' CWGKIF OWNER CORRENUIONRLEWIMEHD <br /> BUSINESS Lt.f2Ct <br /> OWNER'S NAME I'Pt1� V I -9/fC5kO✓(GG PHONE: C9/Cl <br /> fA:r I4 Lur 5 ed-p 17e 74/BGSINE59 Name prep rrmm Owner Hanel Soc Sep orTa'IDs <br /> _ --,L kiccA <br /> OWNERS HotlE ADDRESS �./p 3ffc ST <br /> Cm <br /> Lvwl ' I ,T rE ZIP <br /> owxeR'R MA14NG AGDRess pl6Merm)fnntrwner'A A4tlnaa) AiUrUen o.-Can of <br /> 73Sa 3;21 <br /> MAILING AnRIESSCIfY c' G S un <br /> Tnf of OYmanfN!P: W <br /> CpPPOMT1aN❑ IIAINOwL PAI'fNEPaMiP❑ LOCALAGENCN❑ rOUMT'r AGexCY❑ Rr&re..v—r-1 FED AGENCY OTHER❑ <br /> FACILITY FILE <br /> FAc1uTY ID#: CO{l1VNER <br /> Accouxi lD#: <br /> COMPLETE THEFOLLOW/NG BUSINESS FACILITY INEORMAnaN. <br /> Is IN,a Naw SuMmaa LOCATION or VENic a net previously regulated by the ENVIRONMENTAL HEALTHY- No C] <br /> Ia lhla en Ea:,TINU OGsmeas we's"R N but a NEW TYPE oI m9.I tad Soa[nes!'/ YE NO ❑ <br /> BUSRMSSIFACIUTY NAME(ThiawlB bels OWwErf NAnon HEALTH PlPHRI <br /> ]>:e4.TS , G( <br /> FACItrTYADDpe55pf FAorwYisa AkeyfiesermFIXa vf+s3fv'a Uerggi qs eE J BUSINESS PHONE <br /> ssvy D Ati I RI�d.3Wg.Ro3 <br /> sceA 9(!e 4 -C..aA . <br /> CITYMFAcamrIa a AMHU,F000 Uwror fem VOf4aw'dw tevm'LNn Om T�A'�TT�E LP <br /> BOARD Of SUPERVISOR Dai mer WCArONCODE KEYt KEY2 <br /> MAILING ADOgEna/Or Hea/Hf P&MifUl Dlif Ra Ffrem Fsoct,AEM:eur mCare W. <br /> ag�_noon <br /> MAnWOADMEs5Cm I STATEn 7,Ip <br /> r <br /> Mcc.e: ARM a. Cyd <br /> ACCOUNTA OgES for fees and charge!: OWNER FACILMIBUSINESS ❑ <br /> @LUNOANDCOMeuANCEAe NGY a,V,,T: Lthe undersigned Applicant comfy that l am the Owner.Opener.or AuthorfredAgenf 01 this Business,and <br /> I acknowledge that all PEAAar pM,pENµW,,EYFMCENEVT CNAPe+_•5 and/or HOUVtY C,A =nsuctat'd with this OPOrmce,will be billed to me el the <br /> address Identified above n A< <br /> the eeflh'r ADORES_°for this site. I also comfy that at)informalfen proMded on this appli.flan la Irue and cormcq and that <br /> all regulated ect"'Ithe x91 US percormed in oceordance with all epPllcabb SAN.IeAOUN CDII1f1Y OaSnaneO Code'alMlor Standards and STATE endfar <br /> FEDERAL Laws and Re ulatlws. ,,TJ <br /> APPLICART's NAME: ,E, Gc.,.1 �' /(,LS/�( ✓t <br /> SIGNATURE. <br /> TmE: FleefeFilnr - <br /> GLA)1 t2/ DATe Z7 y 5' p co'AsouIRED <br /> FEE <br /> Dfu ACOyepypl'u Nw..nea eenpe:.A er Us �� l <br /> A PROOMM{EHD 48-024134 Pink)or WATEa SYmsN{EMD 48-02-0031 form TIDW be opmpletad for SOSII EHD regulOted pper0llpn at Is L CA <br /> eaoept UST Program(Use SWRCB forms) <br /> 'RD as OC 035 <br /> 81I2I06 Mml<rpN gecoN-Urcen <br />