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San Joaquin County Environmental Health <br /> N FORM <br /> DATE <br /> MASTER FILE RECORD INFORMATION ���� <br /> o'er=�aA�wt.sun,wrt=e OWrotID* crLseAt NIT IV <br /> ��:.�F <br /> PLETE THE isi7LLOWl1Y(' Nfi7tRMATIAN• t�avrae—Fun�_ n <br /> PROPOM otm+et NAM 4 1J A PHore CLo`1> 1644 <br /> First MI Lest <br /> "'s woe 3 Kp c 1L S O G M AIS Xk_E IZ A<�SO c A3 f o c-S (de 6' I Sot sec/TAX ID* N A <br /> owner l ia. Address i 341 W �0 8 I N�o D D R • � S "F_ a- Dftr*M*f LXENW* /J A <br /> My rJ c cjS zo-7 STATE CA I m 9S Zc,.-7 <br /> owns Ma1Nnp Address <br /> Mailing Address dty <br /> COIRP tATMN❑ Dmn=,AL❑ PArr MMSKCP❑ <br /> FED AGBK.Y❑ oT►+at <br /> F=LM FM <br /> FAmsrY ID CRoss REP ID =ACOX—Mit Irv* <br /> INE FOL 1014 1 <br /> ISM <br /> Is this a NEW Business:LOCATION riot previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEw Type of regulated Business? YES ❑ No <br /> 8U9P BS/FAm.m/SrTE NAPIE "� — C �d F`�l �+ -0 <br /> S-AD--S `� -_ — — StfrrE* 6 <br /> uS"*5S PHore <br /> Crry C=�-T0 C �-T O tJ STATE C4 Zm 9 Z I cj <br /> WNW Cr SuoeevaoR Dana LorwTmN Coos tl�r1 Torn <br /> M&OV Address jrDD9%PBVT th"FbcWCyAr&aw Attention:or Ara Or(gotiwt,N) <br /> MaHkV Address Ctty <br /> STATE ZIP <br /> SIC CODE APN* camera: <br /> T""Pau W SILLING INFos Carte If Billing Party a different firm Property Owner Ar Facility Operator een&fied above. <br /> dtJsacss NAfe 5 6 F2 r Co N S U LT t I.)G , INC . Attention:or Uri of (q parr d) L TE V a 5 tR 1 <br /> MWHng Address P. O. ao* 4( A-0 ) P+roNE .I t 6) <br /> My T?oR ArDo �+1 L,,,S C A H s?6 L STATE Cly pP 9 s 76 Z <br /> for fees and dlarges OWNER FACILITY/BuSINESS THIRD PARTY BILLING <br /> RII.I ING AN71 frlMliJA N(TAf"ICNf W rn;M N— 1,the undersigned Applicant,certify that 1 am the tTvwer, <br /> Operaw,or.IrtMori;d.fdat of this Business,and h acknowledge that all PERMIT f2'ES, <br /> PENAL IMS,EN�CEvE1vTC1tsACEs and/or HOURLY CuAftc2s associated with this operation will be billed tome at the address identified above a the <br /> all information provided on this a d> 06CO for this site 1 also des a that <br /> P application is true and correct;and clot a0 regulated activities will be performed in accordance with all appikabk SAN Jl)At)111N COLxry Ordinance Coda 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 facilitytsite address,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my reprtsentative <br /> APPLICAM NAME PLEAPRVff <br /> C � SIGNATURES— � <br /> TITLE Q V 0 r iJ T / S E RT CO N S v LTl tJ C1 1 AJ C DRIVERS LICENSE*Mg"MI (— O 7 <br /> t i <br /> APprorsd ay Dew Aa rAing Off"NomsrtY casylacw ey D� <br /> 29-02-002 April 25,2003 <br />