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San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> SHAVED ARCAS FOR END Use QM OIYNERIDIII i-71{3� CASE# ,iz.r�o6 330y UNIT IV <br /> OWNER FILE <br /> CoMPLETETHEFoccowjNGPROPERTYOWNER 1ANVRlfATMON.• Cx A,OWNER Cunxovn.rewmiromyEHo <br /> RtopEmYOwlfeeNaAE 1'? ' 1hoNE <br /> FMI Lar <br /> ((�rst �' <br /> BuswEss None I/ 1 Un (Od to&—, SocsWITAx Nt <br /> wn <br /> Oeror <br /> Hnr <br /> e Add.. 1_L- 5-o I}SL� <br /> . -5-,R " one 0. B�BL1 s <br /> Cily 17 1 es-a STATE z- 5/3 <br /> OwrrertAattleg Addrosa <br /> SG A e G5 260� <br /> Matting Addiese City slam 211, <br /> Ty" <br /> CORPORATION'S INOMDUAL❑ PAaTNERSHIP❑ FEDAneNOY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY IO# 2� ' / I CRo"REFID# k5-.?(, INV# <br /> COMBNv <br /> COMPLETE THEFOLLOWINGUSINESSIFACILITYISITEIU tFoRwTio1 <br /> Is this a New Business LOCATION notpret#ously regulated by the ENvlRommENTAL HEALTH DEPARTNIUM YEs ❑ ND,< <br /> Is this an ExlsnnO Business LOCATION but a NEW TYPE of regulated BusintaiaT Yea; ❑ NO,Cly <br /> 10&r1' <br /> BuslHEsslFAcamlSRE NAME I Q r ()()�(„ <br /> $HEADDRESS � rUnn� � �J/ SUrE# f/'�r 6usINES/Sv�/PHONE —rf��7 <br /> CITY' 1� I Or K aTATEC) 71, <br /> BOARD OT aIfPERV150R DIETmCf LOOAIIDN CODE KEY1 KEv2 <br /> Maillt,g AddreseifDIFFEROWrfrem Fa&WAddrese Aaerltlnn:ar Cate Of fepabnalf <br /> Mailing Address CKy STATE Zip <br /> SICCODE APN# Coarsver. <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner arfacility Operator idenUrredabove. <br /> BUSINESS NAME Attention:OrCare Of laPficssAfl <br /> Mailing Address PHONE <br /> CITY STATE Zr <br /> 6aG0f/dVAna#ES4 for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND CaaWuMCE ACxNOwh b&1,4ENf: 1,the undersigned Applicant,certify that I am the OwMr,Operator,or Aorhorlud Agela of this Business,and I acklMwhdge that all PERMIT F£Ey, <br /> P&v&ms,ENPOk o ENr CNMCES and/or HOURrYCHMLES associated with this operation will be billed tome at the address identt#ed above as theAani,Nt'AWs;L=for Nis site, f 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 appscable SAN JOAQNN(AUNTY Ordinance Cod.and/ar <br /> Standards and STATE and/or EBurwu,laws and Regulations- As Ne undersigned owns,open tor,or gent ofthe property located at the brae facility/site address,I hereby authorize the release of <br /> any and All resu1M and envinnmeneAl assessment information m SAN JOAQUIN COUNTY ENVIRONMENTAL HILUBH DEPART ENT as anon as it is avail a and at the same time it is <br /> provided m me or my repress tative. /I <br /> APPLICANT NAME �hfPtEasePRlNr 610NATUR ? <br /> rte 1 <br /> TITLE owl <br /> t-'l0 /ll L <br /> irlApprov d V �Dam�' ACCWDUng OMce Proeessirp ComPlBeeU By Dab I <br /> 29-002 April 25,2003 <br /> FSP 43755 t/3`ft2L( PE- ,L�1su <br />