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F"q y4 rt '.ti Y i st P`iYz <br /> vtia+v,( ds.aY,yrFr" 3 t CR t <br /> ay " a- v� i �irbN�ti±�iA7r <br /> asn.... <br /> ��{, t;HtEN r OitM <br /> DATE �'fjl��) MASTER FILE RECORD INFORMATION <br /> n A'MFR" M <br /> OWNER ID# CASE 5fZ0065/ 37 = UNIT IV <br /> ENVIPONMENTOWNER FILE <br /> NN OtEarfr OWNER CURAEHnroxt-TLE wmfEHD 1:1COMPLETET ERTY OWNER INFORMATION; <br /> PROPERTY OWNER PHONE p <br /> NAME `L - D -146C)C;) <br /> First Mt Iasi <br /> BUSINESS NAME Soc SEC/T"ID# <br /> Owner Home AddressDRIYERY LIaNSE At <br /> l�alSb `fl Nt ' � <br /> City •T2Pf-c>+; STATE (,+:s, ZIP Cf � 37 <br /> owner Mailing Mdress <br /> 17q 5,0 Ulm <br /> Mailing Address City -.-(t,7 State GP LP OI .-7 <br /> \ <br /> roc nc nwurecx.R <br /> e'naonomnx❑ Txnnnnue� ❑ Dsexxco<xre❑ Fan araxrv❑ (arum❑ <br /> Not;l 72 EACII I Fill I= <br /> 'E LL NF A <br /> Is this a NEw Business LMu Tion not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ <br /> Is UIh an E]fISRNG Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No ❑ <br /> BUstiass/FAatJTv/SITE NAME <br /> \'Y\J S La AY�\t.�\1 C? L i I✓F Cis - <br /> SUIIE# BNSINiffis PHONE <br /> SITE ADDRESS <br /> IZqS0 VIt9 rytC-0l-0 �.�`1 - 7�3�-4fxsC� <br /> STATE ZIP <br /> cm cra "i 5_37 <br /> IIMailing Address ifDIFFERENTdom FadlityAddrEss Attention:w Care Of(apodous!) <br /> Mailing Address City gx' STATE LP <br /> THIRD PARTY 13ILLING INFO: COMPle/e if Billing Party-is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> Mailing Address PHONE <br /> STATE ZIP <br /> CITY GtA r7 `7 <br /> AAXQjV t1 Annnccc for fees and charges OWNER FACILHYIBU5I THIRD PARTY BILLING <br /> RT1 11Nr,AND Comer LANff A - FncnmuT: L the undersigned Applicant.certify that I am the Owner,Operator,or Authorized Agent of this Busioess,and I acknowledge that all PEMTFEEs, <br /> PENALITEs,EHFORC EATCHARGFS andlorHOUnYCHARGES associated with this operation will be billed to meat the address identified above as the A[MnNTADDRFRR for this site. I also certify that all <br /> information provided on this application is true and correct, and that all regulated acti\ides will be performed in accordance with all applicable SAN JOAQUN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As We undersigned owner,operator,or agent of the property located at the above facilitylsite address,1 hereby authorize the release of <br /> any and all result,and cmironsne zed assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time it is <br /> provided to me or my representative. <br /> PLEASE PRINT � <br /> APPLICANT NAME SIGNATURE <br /> DRIVER'S LICENSE# <br /> TITLE tiAti.G-1J-7 - I/v �J���. (Marro[o"Multue) <br /> .. ...-,. ti T .. <br /> ;'`AProved B ` <br /> P K-.,<sx . • ..-.' Date;. <br />