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San Juin Cour,-ty Environmental Healtepartm—�::] <br /> �IC <br /> DATEMASTER FILE RECORD INFORMATION "MFR" <br /> Suencn eocec cnu FMn,mennOWNER ID# CASE �A Y ���? IV <br /> iv <br /> E � <br /> OWNER FILEFfRMI� �Ii EALT}{ <br /> COMPLETE THE FOLLOWINGPROPERTY OWNER INFORMATION; LHEc;ro, OWNER LURE ,�% $mf END ❑ <br /> PROPERIYOWNERNAME y 1 — PHONE �1 O� wtD <br /> Y r <br /> First MI Last <br /> BUSINESS NAME C�i ee-R IL—G Pf( r,& )" P. J (� Soc SEE/TAX log <br /> Owner Home Address M J' DRIVER'S I <br /> city uT- C STATE 5o zIP <br /> Owner Mailing Address IIS- A �e C � ��� ,�f'�! L ,`+_ r� Y <br /> Mailing Address City StateState3 g �r !— 2NilE�c C.}',a, rj 1� ��I.C'N/4+'JT �+� Zip Y �33 ` -- <br /> TYPE OF nw <br /> CORPORATION❑ INDIVIDUAL 1-1 PARTNERSHIP❑ FED AGENCY El 4,`` CVMER <br /> FACILITY FILE <br /> FACILITY ID# OD CROSS REF ID# AccoUNT ID# ` r\ Q L n_35 INV# <br /> COMPLETE THEFOLLOWING NFORMATIm <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes ❑ No GY <br /> Is this an EIDSTING Business LOCATION but a(LNEEW1 TYPE of regulated Jn/Busi/ness? Yes El No 9�� <br /> BUSINESS/Rco-ITY/Sr ENAME C.IT C M I/ r� LI'/ <br /> SITE ADDRIESS SUITE# BUSINESS PHONE <br /> fe-rs'.,&.c .n 2 -A -z -30/a <br /> CTT' ��Cil- C-4- STA 4.°!J— uP I 6 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE Keil Kev2 <br /> Mailing Address hFDIFFERENThwm Faci/ityAddress Attention:or Care Of(optional) <br /> ;ailing Address City <br /> SIC CODE l APN# COMMENT: <br /> THIRD PARTY BILLING INFO; Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare OF (optional) <br /> Mailing Address PHONE <br /> CITY STATE zTP <br /> wr.nr..m w..necee for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> RILLINO ANn COMPI.IAN( ,APRNOWI.HDGMRNT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERbnr FFU, <br /> PENm,rrFA,EAFoarza EnTCNARGF and/orHor/ELYCn ss associated with this operation will be billed tome at the address identified above as the Acrorm ,bong.fY for this site. 1 also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance withal]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 the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COG NN ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME PLEASE PRINTJA, SIGNATURE <br /> TITLE .I ��+ pHOTDOOFYl UIRED) r` <br /> Approved BY 1 ' Date b Accounting Otflce Processing Completed By P T `, <br /> 29-02-002 April25,2003 <br />