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San JoaoCounty Environmental Health Drtm2 <br /> ,ATEE:::::::: <br /> MASTER FILE RECORD INFORMATION ''MFRrr <br /> cuencn eocec cno PNn",nm v OWNER ID# CASE# �A Y 6 MOP? IV <br /> V <br /> OWNER FILE PERMIk �tll �rH <br /> COMPLETE THEFOLLOWINGPROPERTY OWNER INFORMATION: CHECKIF OWNER Con E rrH EHD <br /> PROPERTY OWNER NAME ° �Is ,p �y�r p} PHONE '2 OG <br /> Fiat MI Last f+ ry1 1` ( ! <br /> BUSINESS NAME /N - � /N _ ( �C [•l I Gfl M . I ({ � SOC SEC/TA) — <br /> Owner Home Address - (��� lh C f I�'p� f E {� I' DRIVER's lIa <br /> city N _ STATE �b ISP <br /> Owner Mailino Address 1/5- <br /> �tpr , t �. /'". t �g �• /I �•s_, <br /> Mailing Address City 39/2 LPs H J�c ���t ..Ems+ P,C� #('"T4a State O,r+/.�— i zip <br /> TVPFnFnWNCACNTC t� irte,,/ <br /> CORPINDIVIDUALATION❑ INDDUAL❑ PARTNERSHIP El FED AGENCY 114, 1 C OTHER Z" <br /> FACILITY FILE <br /> FAQLITy ID# CR055 REP ID# ACCOUNT ID#: INV# <br /> COMPLETE 12 1 THE FOLLOWING NFORMA7701V' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISRNG Business LOCATION but a NEwTYPE of regulated Business? YES ❑ No 9�-� <br /> BUSINESS/FActunN/SITE NAME `iP rM <br /> SITE ADDRESS w V T �ny SUITE# BUSINESS PHONE <br /> !E-6�rsrc �L P� Zo -y ^3af� <br /> CITYe63"" Tom` . - '. `- SIATF�� Im PIN <br /> BOARD OF SUPERMOR DIsraICTLOfATION CODE KEPI KEYI jV <br /> h <br /> Mailing Address WDIFFERENTIFam Faei/ityAddm" Attention:or Care Of(optional) IN <br /> `:ailing Address City STATE ` <br /> SIC CODE 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:or Care Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE ITP <br /> er�for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> R f' t+n•rF Aruernv PnmreNT: I,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and i acknowledge that all PE HT FEES, <br /> PENALTIES,ENFORCEMENTCHARGE.Y and/or JdOURLYCHARGES associated with this open atlon will be billed tome at the addl'ess Identified above as the ACCOMTAMmEYY for this site. 1 also cel'tlfV 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 the property located at the above facility/site address,1 hereby authorize the release of <br /> onward all results and em•ironmennd assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT n as it is available and at the samc dme it Is <br /> provided to me or my representative. 20' I <br /> �CI�V E� ) PLEASE PRINT SIGNATURE <br /> APPLICANT NAME JQ OPLT ��A" <br /> TITLE f� -•I�^ gI .� DRIVER'S OTOCOI (REbuIRED) _ <br /> JFA, By C`• 1 , Date 7 FAmounting Office Processing Completed By —� <br /> 29-02-002 April 25.2003 — — - <br />