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12/09/2005 05:01 PM r 2/2 <br /> San Joaquin County Environmental Health Department <br /> DAGREEN <br /> I Z 0� MASTER FILE RECORD INFORMATION "MFR" <br /> Sarna. 2V"ma Fran na;n.,v OWNER ID.7 CAN UNIT <br /> OWNER FILE <br /> PLE E WE FOKLOWAW PROPERTY QWN ER kFO&lATIOM• Cures OWNER CuRRwnY urs EHO <br /> PROPERTY OWNER NAME PHONE <br /> Lee <br /> I <br /> ` /RMRM ♦M�Ir <br /> &asntE9s NAMe The, !�(,i Wa i l V ro of SOC Sec/TAX ID <br /> T # <br /> owner Home Address DsuvER s Lxots[At <br /> City STATE IIP <br /> Owner Marlrap Address 210 11�0 G o 1) /- <br /> J <br /> MtdHnp Addrom ati Lord <br /> btnba op 07016 <br /> COVORAW NQ INDNmt1At.❑ PARTWERSHM❑ FED AOENCT❑ OTHEaD <br /> FACILITY FILE <br /> FACMITY M$ f/PROBE REP ID# A=UNT ID# '1 / / fj INv# <br /> CMPLM <br /> Is ft a NEW BuskHM I-OrATION not Prevfousfy regulated by the ENVIRONMMAL HEALTH DEPARTMEPM Yea ❑ No <br /> IS this an EXIO NE Business LOCATION but a NEW Treed regulated Bush im? YES ❑ No JO <br /> Btr5v=5/rtatsrY/SIrENAME Mea f �Q7/O <br /> SM ADORM Sum'# BUSINam PHONE <br /> a"' G ti Al! to <br /> BOARD OF SurERVMR DINOWI I L <br /> Loc►noN CODs IGYl ICeYz <br /> Ma9ftAWn=ff,0 9MENTAomFbddMlyAddrtr Attention:or Cam Of(opgbrNNJ <br /> Mallinp Address City STA zw <br /> SIC Cone APN Jl Cor mkn <br /> THIRD PARTY BILLING INFof Complete if Billing Party 15-differentfmm Property Owner orFadli Operator lowilfedabove. <br /> Btuaesf NA�te Atbenbon: Care Of(opelartsQ <br /> GT(� 4, nn ;, <br /> Malfi g Addtea 1 4/ �/ Va f p E <br /> aTM l STAT! Z!P <br /> A92am Tdaum for fees and dtarges OWNER AdIJTY/BtiSINESS PARTY BILUNo <br /> 1,We wsdtrsiprtd A tlut t Ara the lMne,Operator,ar AaNtarzedAgvrt of Ibla IliYinvs,And I AeiaarledEe ibat PeRNfrF1i�, <br /> P6n+tnts FA7>7RCPMYNr ar aaocisaed with tlrb operation wW be baled m me at the oddness WeaHlied Above n the dm1(m2d?pBESi far this Aire, tA eerNty that <br /> to tafasmatioo provfded oo this app8catiaa is true And eorrerh,and that al!reEWand activitla wW be performed io aeoordantx with ae appLLtabk SAN IOAQuDt COUFfTY Ord Codes andfar <br /> Siaadards And STATE smdMr FLDLRAL Lbws sad ReAulafions Af the ttndeniQasd owner,operator,Or aQast of the pmpery located at the above facility/slte address,l hereby aulho the release of <br /> aey aad d reaps and eav'rameenal nsearmeat InformsJioa b SAtY JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available seal at the me dme it is <br /> provided to me or any representative. <br /> APPLICANT NAMESIGNATURE <br /> PIFASE PRINT <br /> t -r!l7hhA/1'J <br /> TME P Q J T [t�sDTo S LME # <br /> Am--d Of Dabs L A:>�arnns ome.anoa.ono con~By i Date l �t.V7 <br /> 29-02.002 April 25,2003 <br />