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suTheil Mailing Address City <br />COMPLETE THE FOLLOWING BUSINESS / FACILITY / SITE INFORMATION: <br />Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? <br />Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? <br />BUSINESS/FACILITY/SITE NAME •Ry poi tj — 54.0 r is-- <br />SITE ADDRESS -51 0 2, E6r5-t dami 07er SUITE # BUSINESS PHONE <br />CITY I k-i0')/1 <br /> STATE ,,/ ZIP <br />BOARD OF SUPERVISOR DISTRICT (\,ts\ ., LOCATION CODE .r KM, KEy2 <br />Mailing Address if DIFFERENT from Facility Addiess r 4 <br />114)1 tv\esik <br />Attention: <br />or Care °"°Pii°na"Y/11(- gel I <br />YES 0 <br /> <br />No <br />YES 0 No n <br />SIC CODE APN # 13DD dio ID COMMENT: <br />3aquin County Environmental Heal, epartment <br />DATE <br />MASTER FILE RECORD INFORMATION "MFR" <br />GREEN FORM <br />CASE # 1(4413 UNIT IV SHANFIl ANFAIS eon Fmn 'Ice nNI Y OWNER ID# <br />.......—.. . .— <br />COMPLETE THE FOLLOWING PROPERTY OWNER INFORMA7ION: <br />CHECK IF OWNER CURRENTLY ON FILE WITH EHD 12 <br />PROPERTY OWNER NAME -i-tAA 60.1 6 vyJ PHONE ( A A 5-7-,_06,) 7 <br />First MI Last <br />BUSINESS NAME <br />14 01/1 e... <br /> # <br />City MOD E .-S- T -C ., <br />STATE ZIP q535-6) <br />Owner Mailing Address <br />ekNoirx1.._ 0-- ell.\OCPJ e-- ) <br />Mailing Address City State Zip <br />TYPE OF OWNFREPDP <br />CORPORATION 0 <br /> <br />INDIVIDUAL 31. PARTNERSHIP 0 <br /> <br />FED AGENCY <br /> OTHER 0 <br />FACILITY FILE <br />FACILITY ID # <br />I Fl 1 I °toss REF ID # Accourcr ID # 3 I el 4-e viv# <br />THIRD PARTY BILLING INFO Complete if Billing Party is different from Property Owner orFacility Operator identified above. <br />rigoatir(a 0A_ Rg-izt3 4m( p _14 C- <br />Attention: orCare Of (optional) BUSINESS NAME Racc A <br />PiioNE64.)•21-5-7_, 7100 <br />' SavA-a_ Avt a- suTE CA- z. cp.? <br /> <br />AcizolfamAanfiEsS for fees and charges <br />OWNER <br /> <br />FACIUTY/BUSINESS <br /> <br />THIRD PARTY BILLING <br /> <br />Hil I INC AND CONIPLIANeF ACKNOWI EDGMENT. I the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and I acknowledge that all PERMIT FRES, <br />PENAL 77E5 ENLY)RCEMENTOIARGEC and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the .4LIY/WYTADDRFSS for this site. I 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 properly located at the above facility/site address, I hereby authorize the release of <br />any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HE TB DEPARTME oon it is available and at the same time it is <br />provided to me or my representative. <br />APPLICANT NAME ifylt 61.0.A1 t <br />PLEASE <br />PRINT SIGNA <br />TITLE V - k-k-\ tA /I -)!Prs 5 17( ot1S <br />Approved By Data Accounting Office Processing Completed By <br />7-iyiL Li 03 <br />Mailing Address 12.3 4._ E 61: ,7 -M 511ye 21t'; <br />( <br /> # <br />Date t 42 <br />LUNI-IDE TI L 29-02-002 April 25. 2003