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' San Ouin County Environmental Health leartment -, <br /> c i <br /> DATE 'Z �j b MASTER FILE <br /> /RECORD INFORMATION IIMFR' �N ' <br /> <xenrn eouec cno FHn c�nx OWNERID# DDI J /•/� CASE# "0•1/ .t WNI�c/ ly <br /> A IOOCWNERFILE ENVIRUNIALi I HLHL[H <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION: CHECKlF OVVQj4r#&,tFRPqnN EHD <br /> PROPERTY OWNER NAME PHONE 9/6 -333 v <br /> First MI Lest <br /> BuslrvEss NAME1C � �MK SocSEc/TAR:ID# <br /> Owner Home Address l / DR VER'S LICENSE# <br /> City ` STATE ZIP <br /> Owner Mailing Address Zv 1`v I�S V\ rr'�1 L <br /> Mailing Address City CJ �tO Zip `3566 I <br /> TYx nc nw <br /> LARPORAT100 INDIVIDUAL❑ PARTNERSHIPFEDAGEri OTHER 1:1 <br /> FACILITY FILE <br /> FACILITY ID# b0/ CRoss REF/D# IF AMOUNT ID# n0� .y INV# <br /> COMPLETE THE FULL <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an EHISfING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FACIDTY/SITENAME <br /> SITE ADDRESS 'e `.(.(i�c" UITE# BUSINESSPHONE� <br /> CITY STATE ZIP <br /> BOARDOFSUPERWSORDISmICT LOGITION CODE HEMI KEY2 <br /> Mailing Address if DrFFERENTfVmfacilityAddrass Attention:or Care Of(optional) <br /> Mailing Address City ''TATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Comp/eteif Billing Party (its di\Kerentfrom Property Owner or Facility Operator identified above. <br /> BUSINESS NAME �e \� �^Cx �r U 1\ Attention:orCare Of (optional) pew <br /> Mailing Address _J MM I— �t�'�r7bC7 0 C. <br /> P10NE/9/6) $6-888 <br /> 3 <br /> CITY (�,Sc n`' / n_ l/ STA-C?\— ZIP •V�+1 <br /> • QUAfCAaa^'eg&W for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Fill F INC.AND COMP INC'AeRNQwI meMrxT: 1,the undersigned Applicant,certify that I am the Omnan <br /> er,Operator,or Authorized Agent of this Business, d 1 ac owe ge that all PERA(ITFEER, <br /> PENALTIES,ENFORCEMENTCHAHGa and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above es the ACrnurvr AnDREss for this site. 1 also certify that <br /> all information provided on this application is true and correct;and that all regulated activities wN loflifinforroadir:s&W41ii plicable SAN JOAQUIN COUNTY Ordinance Cades r <br /> Standards and STATE and/or FEDERAL Laws and Regulations.As the undersigned owner,operator,or gent of the property located at It ove facility/site add ,Iff-1 <br /> a the release of <br /> any and all results and environmental assessment Information to SAN JOAQUIN COUNTY ENVI t NTAL UEALI'H DEPAR�1 as on r a aY' the same time it is <br /> jl <br /> provided to me or my representative. A <br /> APPLICANT NAMEfiEASE??INT SIGNATURE <br /> "v�STi�T JLLY�.T \ <br /> aa <br /> TITLE I TCS DRIVER'S L ENSE#DS CJ Ll 81 Lf <br /> S`(.C/� fPHOTOWPY RED) .7 C.- 1 _l 1 <br /> APPmved By Date Accounting OlBese Pmmssing ComoleLed BY /�/�,/ _ -.. <br /> c i <br /> 29-02-002 April 25,2003 <br />