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San Joaquin County Environmental Health DbIgiartment <br /> DATEEEECLI <br /> MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> taudgCOAREAS FOR END USE O O1De oAeEF UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NGPROPERTY OWNER INFORMATION. CHECHrr OWNER CURRexnrowrHewiTH EHD <br /> PROPERTYOMNERNAME Q'/ 2 <br /> PHONE <br /> BIMM®e NATE Fast Last <br /> 5,; <br /> SOSISITARIDN <br /> CaesarHowe Address <br /> DwVER'a LICENSE« -- <br /> CRY — STATE .— zip <br /> Owner Mallag P <br /> Address P. Ot B 24IQ 1 <br /> Melling Address City r 5-{, BDM-C I* Ry S i/-o Z 9B <br /> TyPecIFOINTIFFORHIP <br /> CORPORATION IRonteuAL❑ PARTNERSHIP❑ I'MAGENCY❑ OTHeA❑ <br /> FACILITY FILE <br /> FACILITY ID/ CROSs REF ID a ACCOUNT ID d INVN <br /> COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMAT/ON: ���.vvvylllI <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ NO� <br /> IS this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES No ❑ <br /> Butwass/FAcauty/SITENAME SU O— �� (i-10 �WIC <br /> /II J. <br /> v, t <br /> SREADGRESS BUMNEM PHIxf <br /> (866 JaCv� 8r0.ck AlSum# zo _ � s_ 03-7o <br /> Cm L L` ` ✓, STATE A zip Gy� <br /> BOARD OF SUPERVI(SOj R DISTRICT LOCATIONCODE KEYT KEY2 // <br /> Mailing Address ITD/FFERENTBDYR FaeWAddress _ -, Attention:or Care Of(opdoru// <br /> Mailing Address Clly - STATE — ZIP - <br /> SICCODE APN9 COMMENT: <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner orFacility Operator identified above. <br /> Busisu 9NANE Attention:OrMIe <br /> COf <br /> -enc. m , L Mc L.e� Q <br /> Mailing Address Zip <br /> Cl �'r •,. I�—/ SJ PHONE S /���CITY S�f-t �� Lr�• '�W !J STATE [f Z "C <br /> ACGOVAfzAaa Esss forfees and charges OWNER FACILITYIBUSINESS 'I THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE AU"OWLEDGNIENT: L the undersigned Applicant,cenifv that 1 am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERMrr FEE'S, <br /> PPNALTLPS.ERFURCEMEM CRARGPS and/or//OURLY CHARGES a68Miated with this operation will be billed tome at the address identified above as the ACCOUMADDRESS for this site. I also ferNfy 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 Jowpuw COUNry 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 faeBity/tile address,I hereby authorize the release of <br /> any and a8 results and environmental assessment Information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM NT as seen as it is available and at the some tlme it is <br /> provided tome Nmyrepreaentative. / / • <br /> APPLICANT NAME Jai Gdt aeR l LL,.� PMR' SIGNATURE //Y= <br /> TITLE DRIVER'S LICENSER <br /> OC r ` IPXOTOCOPY REOUIflED) <br /> Approval eY On, Z., G' Accounting Office Prooeming Corepbted By Dab <br /> 29-02 10112(09 MASTER FILE RECORD-GREEN <br />