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PrEt' EcL�;ii v <br /> San Joaquin County Environmental Health Department <br /> gRf.� FORM <br /> Dare <br /> 517107 MASTER FILE RECORD INFORMATION ""MFR" ` <br /> OWNENID'S CASES )��V <br /> I � ,L. <br /> OWNER FILE <br /> COMPLETF. THE FOLLOWING PROPERTY F0RMAn9N, CHeCKIr OWNER 0VRRfNny0NRRPWY77N EMD <br /> PROPERTY OWNER NAME ,e e � PHONE �I(v 0611B <br /> First MI Lest w I <br /> BUSINESS NAME aen p.10 Pk er-h �s t,L C 50c SEC/TAX 10 0 <br /> Owner Home Addr=sas li (,J T 1 DpraR's Lllcme V <br /> city STATE ZIP <br /> i <br /> Owner Mailing Address /.15CO 4.k rJ(� Q r �I V J W /3 0 / <br /> Mailing Address City A)W Saar-ct mt /eii BtaZ[�/'�q lZip qg(aQ1 <br /> CORPORATION❑ INDMDUAL❑ PARTMER54iiP❑ RED AGENCY❑ QTHER,� <br /> FACILITY FILE <br /> FACIL]TY ID-T7 <br /> CROSS REF ID# ACOOONT ID JP IN rt? <br /> COMPLETE THEFOLLDWnya BUSINESS / FACILITY SITE INFoRMaaw <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YE& ❑ No% <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Buslness? YES No ❑ <br /> BU9NEs5/FAT,/SITE NAME p;10 Trave-1 Cen` ere t-L'.1, +C k td 34" 145'3 55 <br /> 5�� A°oma <br /> /09989. Har`an Road Sum¢j BUSINM P#1QK <br /> French 1 `Ji//]�y� —r <br /> �ren h V • ` STATE CA <br /> 21P <br /> BOARD Or 5UaERYISCnt DrsrRn;r LOCATION CODE KEYi K-2 <br /> Mailing Address/fmmeR&Nrfrom Faa/ityAddress r� r Attention;or Care Of( a1J�� <br /> 5508 Lonas !/��rLYxiL�/'/ <br /> Malling Address City jl el STATE V/, ZIP 3 '75001 <br /> SIC CODE <br /> �LAPN At COMMENT; <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility OWatvr dentifieddbove. <br /> BUONESS NAME Attention;orCare Of (gipealwW) <br /> P t DoT T tZ�v(=L C pN7f✓2S LLC- <br /> dam rz f}t�1L(NS <br /> Malling Address 5-5-0r6 tx^jlat S rz-U/ c) PHONC <br /> `r" T <br /> V-NC x V I LL <br /> STATE ZIP <br /> Q--A "" q Q� <br /> cw't for fees and charges O / <br /> OWNER FACILITY/BUSINESS HERD PARTY BILLING <br /> RILLIVC,cvn r'c l"rt„vrr ACKVON/t rn��,r.r; 1,the underalgned Applicant,certl�;that I am the Owrtcr,Operator,or Aufh66zcd Agan of this Business,and I ocknowiedge that all PkAwT FEES, <br /> PENaLrtes,&yFOrtCE1t�N7C1'ARets and/or HOURLY CimRrsc associated wits Chir operadon will he billed to me at the address Identified above as the LQ2L! Jaa9=for this site. I also certify that <br /> RU Information provided on this application it"c and correct,and that all regulated activities will be performed in accordance with all app►icabic Sa.NJOAOUN COUNTY Ordinance Codes and/or <br /> Standurds and STATE and/or FEDERAL.Laws and Rcgulations.As the undenigned owner,operator,or aecnt of the property located at the above faellihNite address,I hereby autharuc the release of <br /> any and all results and cmironmenta►ab oNnutnt Information to SAN JOAQLAN COUNTY ENVIRONMINTAL HEALTH DEPARTNILYi as soon as it is avuilnblc and at the same dine it is <br /> provided to me or my represcntauve. <br /> APPLICANT NAME CA-FhG-► e f _G1 V PLEA5E PiUNT SIGNATURE <br /> TI LE Senor Pro A,LIVI �V, D O�vYaECo” D# 3s�9asq 711 <br /> Approved BY Date ,Vt1Jl mounting ofte Processing Compictcd oy Date <br /> :9-0:-002 April 25,:003 , o l b l 9 so <br /> vo I C..Q' <br /> ZO'd ZT:2T ZOOZ Z 6PH T2KOSb:Xpj NOIlDnKSN00 lO�Id <br />