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Q San Jouin County Environmental Health Department <br /> DATE (J/il•�/'D MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> SHADEDARFAAF`OREHOUSEONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOWWG PROPERTY OWNER INFORMATION., CHwxAF OWNER CuaREwrcvonsaewmv END El <br /> PROPERTYOmERNAME —D-c, He0.- k PHONE q�72 -&07- 7505 <br /> First I M/ Lest <br /> BuNNEsSNeMe Glenn S rin $ D�C�t() $,�✓lG. SoCSECITAg ID# <br /> Oester Home Address A/ A DRIVER'SLIOENSE# N/A <br /> city �V T STATE LP <br /> Owner Mailing Menem 505 LB aI Freeway„5cC,Te 1350 <br /> Mailing Addreee City -Da1`CL5 State Zip -7 5 Z L!L4 <br /> CORPORATION INDIMDUAL❑ PARTNERSHIP FEDAQENCY❑ OTHER ED <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID# ACCOUNT IO# INV# <br /> COMPLETE THEFOLLOw/NG BUSINESS/FACILITY/SITE INFORMAT/ON.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ No E <br /> Is this an EYJSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No E <br /> BWINESsIFACiLnYISRENAME 100 \i/,Ckc,4 r`vf \. I1 oo- uinCo, p�1/ /!n3-OZO-l7 <br /> SITEADDRESS Igpy CV�0.r fl-r TAf SUITE# BUSIN/E�SSPHONE non& <br /> 24 CITY 5+zy C- \/� gTATE� ZIP t.l �i0/n <br /> BOARD OF SUPERVISOR DIstteOT «����lll��� LOCATION CODE NEM KEY2 1 L lY <br /> Mailing Addreea HD/FFEREArr70' ,0 rase Atherton:or Care Of(optional/ <br /> o i -- i�2 5 Y /l <br /> Mailing Ackreae City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner or Facility Operator identfied above. <br /> BUSINESS NAME //�� AlenlICac—Care O((TM4 <br /> AMEC GeoMcLkr-'t c.I lnc, M5'. L251t Vis. <br /> MallinBAddrese 1'Gg( E, /�IIOV�a.lAye.,Sut�-e101 PHONE ,551- 892-2921 <br /> Cnv Fres Y\a STATE cA ZIP q 3720-ZcP 59 <br /> dfd:DOVrAnal%M for fees and Charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPITANtIT.ACKNOWLEDGMENT: 1,the undersigned Apphcan4 certify that I am the 0"11,Opermer,or Authorized Agent of this Business,and I acknowledge that all P£RM/T FEav, <br /> PENNn£s,ENFORCEMENT CHAIM.Es and/or nouuY 01A u,,Es associated with this operation will be billed to me at the address identified above as the ACrouMADaRGSS for this site. I also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL laws and Regulations As the undersigned owner,operator,or agent of Me property located at the above facility/site sddreav,I hereby authariae the reksae of <br /> any and all results and environmental assessment information m SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided in me or my representative. f ,t NAMErc..cSlie-K// Ptixvis,��✓l.'PLEAnSE PRINT II SIGNATURE,- <br /> APPLICANT - <br /> TITLE r0 eC.+ Cf�VI rO rllM.e1"l -Qen�t$T DRIVER'S LICE E# / /08�3�T �� <br /> (PHOTOCOPY REQUIRED) �1/ V <br /> Approved By Data Accounting Office Processing Completed By Date <br /> 29-02 10/12/07 MASTER FILE RECORD-GREEN <br />