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SanOaquin County Environmental Healthlepartment <br /> DATEE�I MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> HI OWNERID# UNIT IV <br /> CASE# <br /> OWNER FILE <br /> COMPLETE 7HEFOLLOWING PROPERTYAvv'IEORMATION; C"ICKFF OWNER CURRENnrONFILEWITN EHD I/I <br /> PROPERTY OWNER NAME LJ <br /> PHONE <br /> FirstLast <br /> BUSINESSNAME � �+ ` Q . �`,Lb&h ^la X`,rL)L—i\Y_\ v� ` SDC SEcOwner Home Address ^ ny �• DRIVER'S LICENSE# `-1�(�� <br /> City T2 C^4 STATE/ �, ZIP a 1•�'`I \O <br /> Owner Mailing Address — a�r� <br /> Mailing Address City <br /> State - Zip q 3 <br /> Nos nc rlw <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ <br /> FED AGENCY❑ DTHFA <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID# ACCOUNT ID# INv# <br /> FBIUSINE�7/FA�/SUE <br /> Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> ISTING BUsiness LOCATION but a NEW TYPE Of regulated Business? YES [[1 No ❑ <br /> ILITY/SITE NAME /.'1A <br /> 1-fRYFL <br /> a3 SUITE# ag`SQ F55 ipSTATE uvRwSORDISTRILT LO7rlim CODE KEy1 <br /> KEY2 <br /> Mailing Address ffOIFFERENTfMM FadfityAddm <br /> --At <br /> in f Co ��o� r <br /> --- �e�oo� li <br /> Mailing Address City <br /> STATE ZIP <br /> SIC CODE APN# COMMENT; <br /> THIRD PARTY 131L.LIN6 INFO; Complete if Billing Party IS different from Property OWEIer or Facility Operator identifiedaboue. <br /> BUSmEss NAME La OV Eflav 1k JI, Lon.Q Attention: Care Of (opHonaf <br /> TT%- r t P1 eta <br /> Mailing AddressCITY <br /> for fees and charges OWNER T 67 / <br /> FACILITY/BUSINESS THIRD PARTY BILLINGLLING <br /> BITI INC,AND COMPF TANCL A ; 1,the undersigned Applicant,certify that I am the Ow un,O eratoq or Authorized <br /> P£NALTIEY,ENFORCEM£NTCKARGEd' P riyad Agent of this Business,and I a oor this that all o certify <br /> and/or ROURLYCnARCEs assotiated with this operation will be baled to me at the address identified o as the for this site. I also cerdty that <br /> all Infororafion provided an this appbcafion is true and correct;and that all regulmed ac&ifics win be performed in accordance with II a pncab JOAQUM COUNTY Ordinance Coda and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at e a acHity/site address,1 hereby authorize the release of <br /> any and all results and environmental assessment information no SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR As soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME VeNtti M. t^C T "' SIGNATUR <br /> TITLE ll C. G�h DRIVER'S LICENSE# Q q /� 00M'� O� <br /> C (PHOTOCOPY REOUIRED) CA- <br /> APProved BY Date Accounfing Office Processing completed BY <br /> Da e <br /> 29-02-002 April 25,2003 <br />