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San Al Iquin County Environmental Health Department <br /> DATE ;1vLY 2'�/ tot o MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> SHADei ARMS FOR EHO USE ONIyIOWNER IDN CASEY UNIT IV <br /> OYIMER FILE <br /> COMPLETETHEFOLLOW/NGPROPE RTY OWNER INFORMATION. CHROI OWNER COHNEMTLYOHFAFAM,EHD <br /> PROPERIYOWNER NAME PHONE <br /> First M, Last <br /> BUSINESSNANE <br /> OwnerHoma Address <br /> ORNER'3 LICENSES <br /> city STATE LP <br /> Ownx NAlllnp AHNea <br /> Meltlrp Adtlrep Clly S (�(� �ie-j— at,"CA 21P47 53 362 <br /> CORPORATION❑ f •�t� INDIVIDUAL[I PARTNERSHIP[] FEDAOENCY❑ OnIER� <br /> FACILITY FILE <br /> FAz;; DROs9 REf IDR ACCOUNT ID# INV# <br /> COMPLETE THE FOLLOWING 8USINESS I FAC ILITYI SITE/NFORMAT/ON.' <br /> IS this a NEW Business LDCAnON not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ Na O <br /> Is this an E)OSTING Buelness t.00mwbi but a NEW TYPE of regulated Business? YES [a No ❑ <br /> BWINE89IFAcILRY/afrENANE F10,21-1 'J ( i <br /> SITE ADOaE88 .(.LLIZ 53 �OIA �A <br /> TH (rF Po"tT WlrY SURES BUMeNEPHONE � <br /> Criv �a.}'J L�"..'A STATE CA ZIP NSS`S33/W <br /> BOARD OF SUPERVUOR DISTWLT LOCATIOHCOpE KW NEY2 <br /> Melling Address KO/FFERENTIh m FecftAddrase Attention:or Care Of fopr/mssO <br /> Melling Adchmsa City STATE ZIP <br /> 810 CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete ifBiliing Party is different from Property Owner orFacility Operator identifiedabove. <br /> ,y BUHINE68 NAME 1 ACailtlOn:NCOra Of <br /> �ISy\// � SzuVA - ov�Ks f PSsoc cA(A--,V-3fopMan`e <br /> tz <br /> Melling Addraaa T/CAoe' cetvi'ET< D121vt r 1L4rTF ( U--7- PHONE`y1G oa <br /> Cm H O G STATE C�- Zv SSG 3' <br /> U <br /> Afxof/AfZAOaRf:ss for fees and chargee OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> gaurvr.AND COaIPLTANCE A[RumvLEDrs ENT: 1.the undersigned Applicunl,cerdit that 1 am the Ooner.OperamA or.Nmhodred.igent of this Business,and 1 aeknowlodge that all ja,,,TFEa <br /> Ftv.unrs'.ENFORCE,1nT(,jV,mdAud/or/feeRAT CNasoa ASMednad with this Operation will be biped to me at the address identified above as the ACCor"Tdt! Rf_sc for this adds. I elm certify that <br /> All information provided ILO this application is true aad correct:and that all regulated xrd hies%II be performed in accordance with All Applicable SAN JnAQsoN ROUNIV Ordinance Codes andlor <br /> Standards and STATE and/or FEDEIUL Laws and Regulations.Aa the undersigned owner,operator,or agent of the property located at the above faci'tglaikk,,m dress.i hereby au thoriu the relesse of <br /> any and all results and envimnmenml assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTn DEPARTNIEN aoen as U I,. <br /> end x1 hI same Time II is <br /> prnvlJed m me or my represenmlhe. <br /> APPLICANT NAME t�l-IV ESL- YA'N PLEaeE PRINT SIGNATURE <br /> TITLE 5TWG cnae ,oy lL`C DRIVER'S LICENSE# <br /> (PHOTOCOPY REOUIREDI <br /> APProved eY onto Z U Aeeaunsnp Dmoa ProeeeeIng Completed By Dob <br /> 29-0_' 10110] %IAST[R FILE RECORD-ORFEN <br />