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10 it 0 <br /> San Joaquin County Environmental Health Department <br /> DATE GREENFORM <br /> MASTER FILE RECORD INFORMATION ccMFRop 1 1 T <br /> 9 EHC nee CNe OWNER IDM 0 --CASEI UNI • IV <br /> OD 54 <br /> _ OWNER FILE <br /> F.6,gAdd'maut <br /> OLLOWINa PROPERTY OWNER/HFURMA nod/• cxec2rlr0 EER./euNxEyvwoeraewrrN END <br /> PHCNEte+LLJ <br /> L (RIE 2,IL �9ECITAN IDI <br /> (4-/A DIV ER'aLICPNSEN <br /> y�' STATE LP <br /> `—' 0wneaglllllep Addreu :t Z t C <br /> EL <br /> Mailing Ackres.City SI 0 f.•.71L�'l. pa` �1^ bP 9SZ 3 <br /> Cw+vacanex❑ Ixolvlouu[I PAIefNFABNIP❑ Fm AsPNCY❑ orNEa❑ <br /> FACILITY FILE <br /> FAOIt IOM Cabae REr IDM Aoncuar lOM <br /> COMPLErETHEFOLLow,va:BUSI NESS I FACILITY I SITE INFORMATION.- <br /> Isthis aNbv+Business LOCATiDN notpreviously regulated by the ENVIRONMEwALHEALTM DEPT.? YEE El NOE- <br /> Isthis an DllariNG Business LocATION buta NEW//TYPE ofregulaat�ed Bus�i)ness?�{� Y(EiS ❑ No/oX <br /> BUSINESSIFACIMIS11ENAME op Yrtr h /'� dCr K..t L'L iJ"� W rLL� "r' r+a <br /> &reAppaPae .ro:–}I.,,,rc C'{" fi at F...-, r-a. lige OZ '3 R..'.s <br /> 1 ,.� I ` tA" ':'12•I L9PrO.s'l°9urtee BaaINISe PNONE <br /> MCIty <br /> a DldrWbT IFFERENTrMMFadNtyAddrees � ( Attent'on:pr Caleb f Q <br /> y BTAW LP <br /> APNI'' r -COMMENT: ' <br /> THIRD PARTY BILLING INFO: COMP/ete/fBilling Party is different hom Property Owner orFacility Operator Identified above. <br /> t <br /> SuesissNAMEPS <br /> 7 Attention:erOara Of(OPd'auU r+ rL pwr`r` <br /> t v r:•� e.. P x�f�ra•c>t _ <br /> Melling Addrees (tfII-y..6 .S. /�l o....'1=41.a.. i�vL. PH-a 2.� 9 z34)— S•'K <br /> On �tt'T h/o n STATE CA 71P 95 3 <br /> forfees and charges OWNER FAaLrrylBusiNEss THIRD PARTY BIwuO <br /> BCONPLIANCE A 0O*% : 1,the undersigned Applicant,eerdfy that l am the Owner,op.&,,,ovAerboAsd AK+nf df thb BUdstan,and I kidder ledge that.11? aFrttr, <br /> PENAGRSr;ENtua<sNENr Crullers a¢dbr XOGGY LT(MG6 nuodaledwith tM1b oprnNan w1O be bgied M me at Ihaaddtas identified above as tIrA=uwADDR=for this site.T obo certify that <br /> all informeeon provided on she appllallonb ave Bud wrtat,and that.W regulated aefivIdes will be performed In.+ceordance wishall applicable SAN JOAQUm COuHvV Ordinance Codes and/or <br /> Standards and STATE and/or FT waw Laws and Regandotss.As the uudenigeed owner,operates,or agent of the property touted at thea T as <br /> <br /> <br /> <br /> <br /> <br /> <br /> Approved ay Oab AeaeuntlrG 011lee PmoeeelnO ComplebdB Owns �J D <br /> 2M 10/12/WMASTER FILE ORD-0RMN <br /> �fk•� <br /> SP <br />