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40 <br /> q San Joaquin County Environmental Health Department <br /> DATE �?- / MASTER FILE RECORD INFORMATION 'MFR' GREEN FORM <br /> Cu • FOR HO EON OWNER IDR UNIT IV <br /> lJoo13 b <br /> orrXB9e TILE <br /> Comwe x7wFoeeo*%wPROPEM0VMERAwommnow JUN 1 1 200Re nrava[�arnfEHD� <br /> PROPER Oiwtenwaa San Joaq ul'n RTD I I Pmo tE=ENVwQNMENTHE 4H <br /> First MI <br /> Bt1aNEssNALE pan Joaquin �2ty ICA& TV-in crTct'}l'o Vl l�;s�vi U. soca�fTnxwR <br /> Om-*to P o Bok 2010►o DRNEfiiRLCENSE: <br /> CRY stackton STATE : zr 952 01 <br /> (toner Maung Address; ntit A5 abo__e <br /> v <br /> Melling Addresses City ..XVK42 a`S Ci lWVe atate zo <br /> CORPORATION❑ INIBYIDl1At❑ PA"Isn HIP❑ F®AGEor❑ OtRER <br /> FACILITY FILE <br /> FACIUTYIDi CROSS REr IDR A=uw IDR C `01 ti INVE c l <br /> pT p <br /> Comm ErE7HEFoLLowNoBUSINESS/FACILITY/SITE lwonlroJ <br /> aArn (J O <br /> Is this a NEW Business LoCAnoN not peeviouldy Mutated by the ENVIRoNMENTAL HEALTH DEPT.? YEs ❑ No <br /> Is this an ElasTiNG Business LOCATION but a NEIWTYPE of regulated Business? YES+ No <br /> SJoayUlIb C <br /> ck0c)BUSINESSIFAGITYSRENAME -lic � <br /> BTEAWRESS izo .v. �� - V32-6 ,(. 3023 E MO s+) $Mr.R t Nom 7o be <br /> CITY JtD -[•�n STATEC /I ZIP <br /> BOARDOFSUPEWSORDISTROCA <br /> CT LTION CODE KEPT KEY2 f 1 J <br /> Meiling Addross fFD#7WROV7'f a F&cAyAddesa :? Attention:lir Cee Of 1pPffo'mill <br /> Mesirng Address City :.JL i r 1( 1 STATE �-r'j ZIP <br /> SIC CODE APNR CorwEw: <br /> TNIIto PARTY BILLING INFO: Complete it-Billing Partys is different from Property Ownar orFacirefy Operator identiTedalwve. <br /> BUSINESSNAME I D (� / I'�^c K t 1 Attention:%Care Of fOPbanall <br /> dd <br /> Melling Areaa 3 EI 5/l—(•/�OJ 1'�C c� I W PHONE <br /> Cm 19I,/T`Af_ 1_l r,,G i_ STATE � zP q r-(,55 3 <br /> amm for Teas,and Charges, OWNER FACILITy/BUSINESS THIRD PARTY BILLING <br /> 131UING Alla COMPLIANCE ACKNOWLEMMENT: 1,the undersigned Appfiwnt,certify that 1 am the Owner,Operator,or.tuMmiSedAgem of this lhlsines&and!acknowledge Matas PERMIT Fen'. <br /> PE.wLnn,ENn)RCENEAT CHAR(:n and/or HINW i Cr fii;nassoriated%ith this operation will be billed to me at the address identified above as the ACCOL'NIAIyy for this site. 1 abo certify Mat <br /> all information providedon this application is true and mrreet;and that all regulated actiyides will be performed in accordance with all applicable SAN JOAQNM COOm Ordmanm Codes and/or <br /> Standards and SFATE and/or ltiiim .Laws and Regulation. As the undersigned owner,operator,or agent of the property located at the above Adlityhite address,l berth%authonee the release of <br /> any and all resWti and environmental assessment information to SAN JOAQUIN COUNTY ENA'IRONMENTAL HEALTH DEPARTMBNr soon u it uavailable an al the same fine it is <br /> provided to me or my repress mifim <br /> —r- PLEASEPRINT <br /> APPLICANT NAME <br /> �a ahan `iri SIGN �._ <br /> TITLE f ilk EVI�IfG✓I✓/I�f1�c" eO✓y5il �}cx�;' DRIVERSUG• SEX <br /> (PHOTOCOPY REOUIRFDI <br /> Approved By DMa Accounting Orfce Procaasing Completed By Dale D <br /> 29-02 10/12;07 0 MASTER FIL8 RECORD-GREEN <br />