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Ma Y. 6. 2004 12` 19PM Aa ced Geo Environmental No. 4984 P. 2 <br /> ,AN JOA10N I,OUNTY CNVIRUNMENTAL HEALTH p r RTM <br /> MASTERFILE RECORD INFORMATION FORM <br /> J <br /> SNADEDSEO7roNs wHEHD Use ONLY .(;, � p,� •�" .c �; .., � .. <br /> OWNER FILE PERMIT/SERVICES <br /> CowlLE7r7weixLow7NGBV9INi!w OWNER AAPmmmmm, GHewrr.OYYNCR CIAWMMI6TVNrlle Wt,mr"D❑ <br /> BUSINESS PHONE: <br /> OwNER'8NAME '41LA s PAn1TtA zoy) s3z-77eo <br /> First MI Leat <br /> BUSINESS NAME(if ddkrent rrwnOmw Noma) Soo Sec TBX 10 <br /> ()WNFR'R Hnur AnnaFA.a ro nose ioae <br /> CITY— <br /> Tracy I STA ECA ZP 95378-1036 <br /> OWNER'S MAILING ADDRESS(If oalerenrlrwnomes*I etheee) Aaentlon orCane of <br /> MAILING ADDRESS C1TY STATE IIP <br /> T/PEOFOYIIEFMKIP. <br /> CORPORATION El INDnTNALEA] PARTNUMMP❑ LooALAr5MY Galan AGOTDY❑ STATEAGEMNE] FEDAGEtt OTHER❑ <br /> FACILITY FILE <br /> FA00_rry. i.. 0001tewgill:i. _TWMA67.N p <br /> .. 'v rW <br /> CbAv%ETETHEF•OLLow/NG BUSINESS FACILITY 1APrORAFA770A6• <br /> ka Dnau NeH euainaa�Wuwriun ur Vtmui nul pe•mNrualy rgluleled wy urs eunnunnenrx.Hu�in Perrfaneela�T Yoe ❑ Nu '(] <br /> Is this an BasrtNc Business LOCATION but a NEW TvP of regulated Rusllless7 YES ] No ❑ <br /> SUSINESSIFACLLrry NAME(Thb will be the BLele wild :cn the HEALTH PERMIT) <br /> Padilla Property <br /> FACILITY ADDRESS(tr FA LU is a MO&LEF000 UNror Foov VV#aE the COMM186ARYAnORFsaI BUSINESS PHONE <br /> 14745 N THORNTON RD (209) 632-7780 <br /> Sus A <br /> C17Y(if F.Aun sa Mos Foao Uwror Fox V&urtE use the Qamm�Cm) STATE Zip <br /> LODI CA 95242-9509 <br /> � � q,� i � ru c � . <br /> MAIONa Aonmss for PfeaVd7 ftrizi (tl DiFFEREN7ftvm FA4KWAdrrMSS/ AtLenuun oroare of <br /> PO BOX 1036 Andy 2arakani <br /> MAn.INa AnnREss CITY TRACY STATE CtI, 2jP 9,370-10.)c <br /> YIN 'll fel II <br /> ACCOriArrAoDRES3forfees and charges: OWNER x❑ FACILITY/BUSINESS ❑ <br /> RILLIND AND COMPLIANCE AOKNOWLEMNIENT: 1,the undersigned Applicant,carDiy that I am the Owrw,Operator,or Authorized Agent of this Business,and I <br /> acknowledge that all PERMIT FEES,PENALTIES, ENFORCEMENT CHARGES andlor HOURLY CHARGES associated With this operation will be billed to me at the <br /> address identified above as the AccouNTADDaess for this site. I also certify that all information provided on this application is true and correct;and that all <br /> regulated activities will be performed In accordance with all appllcabio SAN JoAQuN Couht Ordinance Codes andlor Standards and STATE andlor FEDERAL <br /> Laws and Rogulattlons, <br /> APPUWNT'SNAME: Mila Padilla SIGNATURE: <br /> rrtaero <br /> TITLE: Property owner DATE j�f I,�� DRlvat'sUcesNle <br /> PtarocoPr RP.Ganm <br /> a PbM AY(amn AAAI-MU PIn4)nc WA•rcn c�(FNn AA.II'JlInQ3 mn _A nnneay�rtltier CYn roerd�ro,1..r,—fl— s1 Ihls I flr,&Tln <br /> CHO4 4NT 12-035 rari(Udi In ris} ,(t/V/'Jt <br /> EH04n-02-035 • �A MacierfileRecvrd-Green <br /> 11/27107 f)� <br />