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San Joaquin County Environmental Health Department <br /> DATE60 <br /> FORM <br /> O MASTER FILE RECORD INFORMATION "MFR" �� - P/ <br /> Suenrn eacec MR FMID QWNER ID# CASE At JUN UNIT04 IV <br /> OWNER FILE iRONNII_NI iILAG� <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMA77ON: • OAECKIF OW"w"M EHD ❑ <br /> PROPERWOWNERNAME A AAA PHONE ^'��2 <br /> First MI Last <br /> BUSINESS NAMEI 1 _ <br /> e t P I^e C o ref Q n t SOCSEC TAX ID#, <br /> i <br /> Owner Home Address <br /> City r7 Ln <br /> �J U1.5"� STATE T Z.IP vV Z <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> T nFDw <br /> CORPORATION INDMDUAL❑ PARTNERSHIP❑ <br /> FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID# ACCOUNT ID# INv# <br /> PLETETHEF LLOWING NF RMATI N' <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No Id' <br /> BUSINESS/FACILITY/SITENLTYAME {QC(��.) 1Y urvl S ��}10-� <br /> �u� O S . 't�[,l�'1'eC�Cs sDTfE# BUSINESS PHONE <br /> `"" c czc zoq 83 5. 3�Z3 HATE Z. 3 T-) <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEPI KEY2 <br /> Mailing Address ifDIFFERENT hum Facility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# / rCOMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identYBLd above. <br /> BUSINESS NAME Attention:arcane Of (optional) <br /> Mailing Address PHONE <br /> Cm <br /> STATE ZIP <br /> caguA74aag w for fees and Charges OWNER FACILITY/BuSINES$ <br /> THIRD PARTY BILLING <br /> R l 1 ANG AND COMPI FANCL AL&tcQALE ^. 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all P£Run-FE£s, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the ACETHINTADORPS forthis site. 1 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 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,I hereby authorize the release of <br /> any and all results and envir ant assessment' formation to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT As soon as it is available and at the same time it is <br /> pro,ided to me or my rept Ata' <br /> APPLICANT NAM _ �.// .wI_ PLEASE <br /> KAiI� <br /> ocTq rlt SIGNATURE <br /> I <br /> TITLEQ$�ATCGt7S .De _W4fU <br /> nC7 DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIRED) <br /> Approved By pate Accounting 01fice Pmmssing Completed By Date <br /> 29-02-002 April 25,2003 �f <br />