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0 0 <br /> San Joaquin County Environmental Health Department <br /> 5I1 IbH GREEN FORM <br /> °"'� � MASTER FILE RECORD INFORMATION "MFR" <br /> r FHn UNIT IV <br /> OWNER FILE <br /> MPLE7E 7NEFOLLOWING PR PERTYN INFORMAnONe Cmca.ne OWNER CzaurD. <br /> xraF vWM END <br /> PleoPalY owNER NAreE .��.,,. 5 h tzy 1 rn Gree. P— 3 z$ /If 9 g <br /> First M/ Lag <br /> BI6ef69NmE UJ�Lr�.4�dl1,se5 CfbrwAsrGftn-� E/�6,6w.o(.Tv.n� S0CSMiTarlDr <br /> OWDer Home Address 12bff6 N • Gain YV`f '+V- DRtYER'SUCIMEN <br /> CRY Lv p i y STATE C/a- zas <br /> Owner Mailing Address b4 D N • EL p tT'Ea a D ej <br /> Mailing Address txy S F a C k r✓ state CA I ZIP 9 5 Z o Z <br /> Ca+a rint, ❑ FID AC,ENCY❑ Onsist❑ <br /> FACILITY FILE <br /> FAr]lIT'ID NCROs6RHIDN ACCOUNT IDN � gNYN <br /> s CJS <br /> Or <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? vile ❑ No 0 <br /> Is this an Elnsnive Business IACATION but a NEW TYPE of regulated Business? yE s ❑ No <br /> BDmIP.S/F04Mppr/SMNAME FCV,Mem lr1e,e, <br /> SIEADunrSSS t(OHO � el <br /> s # BUSINESS P"Otle <br /> cm <br /> sTATE C A IIP <br /> Mailing Address lfDIFFERE/Yrrrwn FedillyAddiess Attention:a fire Or(op(fOrod) J <br /> 0335 Creel. r".\ C 'sq 0T3LEI�� \V\/ <br /> Mailing Address City 5+o(,�'F':,\..,, STATE C ^ IID 15 2 09 C1 <br /> rf y <br /> THUD PART~Baume pilro: Completeif Billing Party is different from Property Owner or Facility Operator idenMlledadove. <br /> B11tat1Ef<NA f t r a 2 2 ro A Attention: VCam OF(apWHV <br /> M.mrg Adc11 \1 14 MAI,_ StreC �— Pf10NE 60-)373$—"19 k- <br /> OOT �Sca1ty� STAM! C ffi C153-L,, <br /> AcaovwxAN`O for fees and charges OWNER FAe1LITyBHSINFss THIRD PARTY BILLING <br /> RIIIINLAsnroMa uvrrnrexnw ro mar - Lthe undersigned Applicant,artiry that l am the Oxxer,Operater,orAurheriied Agehl of this Budnea,and tacknoxl ge v1�PFRH?FYtS, <br /> PENAEDE.1,£NrnAee WCr ,U.nd/or ROUALYCHA Eraaadstedwith thisopratlon will be billM to meal the address identified above..theACLUUNrAMRFa for this sit, ldsocetifythat <br /> dl inferm.Its.provided an this application is true and carr.,;and Nat ail regulated advilin rill be performed i.aardance xah dl applicable SANJOAQMN CotnMr Ordinance Codes.nd/or <br /> gundvda and SrArE and/..FEDEpAL Laws.lid Regulmionx As the nnderdgned oves,operalor,ar agent of We property located at the above facilitybiteaddrnl,l here by. thoriu the release of <br /> any and til..Its.ed environmental aveamenl information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it if v'ilabk t the ame time it is <br /> grovided to see or mv,,pr..ft iv.. qp����,g�+r <br /> AP I-ICAMI NAME / -� 6 o(j�/ 1 -C H�� SIGNATURE/ <br /> l9 11�� f ✓1.�� <br /> f. <br /> TITLE , /• f7• DRIVER'S -71 <br /> LICENSE N <br /> V ( fIM10CLPY IetQUlRFD1 <br /> Appeeed as Dab 11 ACmunMrp Off.NecaMne C.0stad By Date <br /> 29-02-002 April 25,2003 <br />